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INTESTINAL  OBSTRUCTION 


ITS    VARIETIES 


WITH     THEIR 


PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT 


SIR  FREDERICK  TREVES,  Bakt.,  Iv.C.V.O.,  C/B., 

'"f.r.c.s. 

SERGEANT    SURGEON    TO    H.M.    THE    KING 

SURGEON    IN    ORDINARY    TO    H.R.H.    THE    PRINCE    OF    WALES 

CONSULTING    SURGEON    TO    AND   EMERITUS    PROFESSOR    OF    SURGKRY    AT    THE    LONJJON 

HOSPITAL 
LATE    EXAMINER    IN    SURGERY    AT   THE    UNIVERSITY    OF    CAMRRIDGE 


WJTH    J  is    ILLUSTRATIONS 


NEW     AND     KEVISED     EDITION 


JVEW     YORK 

WILLIAM     WOOD     &     COMPANY 

1904 


en 

CD 

to 


PRE  FAC  E. 


The  first  edition  of  this  work  was  published  in  1884.  It 
was  ill  substance  the  essay  to  which  the  Jacksouian  Prize 
had  been  awarded  by  the  Royal  College  of  Surgeons  of 
England. 

During  the  fifteen  years  Avhich  have  elapsed  since  the 
book  came  into  existence,  extensive  additions  to  our  know- 
ledge of  the  pathology  and  clinical  manifestations  of 
intestmal  obstruction  have  been  made,  and  a  great  and 
far-reaching  change  has  affected  the  modes  of  treatment 
of  that  disorder.  To  embody  these  additions  and  to  do 
justice  to  this  change,  it  has  been  necessary  to  re-write  the 
book  almost  entirely,  and  to  introduce  many  emendations 
into  such  parts  of  the  original  essay  as  have  survived  the 
vicissitudes  of  fifteen  years,  and  have  been  retained. 

The  entire  arrangement  of  the  work  has  been  altered. 

It  has  been  found  more  convenient  to  divide  the  subject 
into  three  distinct  parts,  and  to  consider  first  the  pathology 
of  intestinal  obstruction,  then  its  clinical  manifestations,  and 
tinally  its  treatment. 

In  the  account  of  the  treatment  of  the  trouble  I  have 
refrained  from  introducing  the  actual  details  of  the  various 
operations  named,  since  such  matters  are  very  full}-  discussed 
in  the  text-books  on  Operative  Surgery. 

A  large  number  of  new  illustrations  has  been  added, 
for  which  I  am  indebted  to  Mr.  Berjeaii. 

Frederick  Treves. 


6,  WiMPOLE  Street,  W. 
June,   1899. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/intestinalobstro1904trev 


CONTENTS 


Introduction 


1 


PATHOLOGY  AND  MORBID  ANATOMY. 

CHAPTER 

I.— Genekal  Pathology  ov  Intestixai,  Obstkvction  .  .9 

II. — The    Morbid    Anatomy    of    Pakticllar   Forms    of   Intestinal 

Orstrvction,  Strangulation  bv  Bands,  etc.  .  .       24 

III. — Anomalous    Forms    of   Obstruction    Due  to    Isolated    Bands 

AND  Adhesion?  .  .  .  .  .  .75 

IV. — Internal  Herxi.ti:     .  .  .  .  .  .  .102 

v.— Volvulus       .  .  .  .  .  .  .  .126 

Yl. — Intussusception  .  .  .  .  .  .  .     141 

YII. — Obstruction    Due    to    Foreign    Bodies,    Gall     Stones,     and 

Enteroliths      .  .  .  .  .  .  .185 

Ylll. — Stricture  of  the  Intestine  .....     202 

IX. — Obstruction  Due  to  Tumours  Growing  i-rom  the  Bowel  Wall     259 
X. — Obstruction    Due    to    the   Pressure    of    Tumours,  etc.,   Ex- 
ternal to  the  Bowel  .....     2GS 

XI. — Fji:cal  Accumulation  ......     27a 


PART    II. 

THE    CLINICAL    MANIFESTATIONS. 

I.  —The  Clinical  Varieties  of  Intestinal  Obstruction 
IT. — The  Significance  of  the  Leading  Symptoms 
ill. — The  Symptoms  as  Modified  by  the  Position  of  the  Obstruc 
tion        ....... 

IV. — The    Diagnosis    of    the    Differe.vt    Forms  of  Intestinal  Ob 
STRUCTION  ...... 

V. — Acute  Intestinal  Obstruction        .  . 

VI. — The  Course  and  Prognosis  in  Acute  Intestinal  Obstruction 
Vir. — Chronic  Intestinal  Obstruction  .... 

VIII. — The  Course  and  Prognosis  in  Chronic  Intestinal  Obstruction 
IX. — Chronic  Intestinal  Obstruction  Ending  Acutely 
X. — The  Differential  Diagnosis.     Errors  in  Diagnosis 


285 

289 

310 

321 
323 
373 
391 
430 
435 
439 


JNTES  TIXAL    OB 8  TR  U(J TION. 


TREATMENT. 

CHAPTER  PAGE 

I. — The   General    Theatment   of    Acute   Txtestinal   Oisstkuction  449 

IT. — The  Opeuatiye   Treatment  of  Acute  Intestinal  Oksthuction  475 
III. — The    Operative    Treatment    of  Particular    F(jrms    of  Acute 

Intestinal  Obstruction          .....  494 

IV. — The    Prognosis     After     Operation     for     Acute     Intestinal 

Obstruction       .  .  .  .  .  .  .519 

Y. — The  Treatment  of  Chronic  Intestinal   Obstruction     .             .  523 
YI. — -The  Pp.ognosis  After  Oper.ation  for  Chronic  Intestinal  Ob- 
struction          .......  559 


Index  .........     561 


LIST   OF   ILLUSTRATIONS 


Kader's  experiments  to  demonstrate  the  production  of  Meteorism    . 

Great  sacculation  of  the  Transverse  Colon  due  to  a  Stricture  at  the  Splenic 

Flexure  ....... 

Stricture  of  the  small  Intestine  with  Pouch   .... 

StrangiJation  by  a  broad  Peritoneal  Band  passing-  between  two  adjacen 

Coils  of  Ileum  ....  .  . 

Strangulation  of  the  Ileum  by  a  Y-shaped  Band  attached  to  the  Fundus  o 

the  Uterus         ....... 

Slrangnlation  of  the   Ileum  by  complicated  Bands  passing  hetween  the 

Uterus  and  Ovary         .... 
Strangulation  of  small  Intestine  hy  a  solitarj'  Band  attached  at  either  end 

to  the  Mesenter)^  ...... 

Strangulation  by  a  Band         ...... 

Strangidation  by  an  adherent  Diverticle        .... 

Strangulation  by  Meckel's  Diverticulum        .... 

Diagram  to  show  a  possible  method  of  snaring  by  a  long  liganiorit 

One  mode  of  Strangulation  by  the  Diverticulum 

Strangulation  by  the  Diverticulum  hy  a  double  Knot 

Portion    of   Ileum    strangulated    by  a   tibrous   cord    (the  remains  of  th' 

omphalo-mesenteric  duct)  which  terminated  in  a  rounded  mass  of  fat 
Stenosis  of  the  Ileum  above  the  origin  of  a  Meckel's  Diverticulum 
Multiple  Sacculi  or  Diverticula  of  the  Small  Intestine 
Distension  Diverticula  ..... 

Diverticulum  of  the  Lower  Jejunum 
Portion   of   Colon  constricted  by  one  of  the  appendices   epiploicte  which 

has  become  adherent  to  the  omentum,  which  is  itself  attached  to 

the  bowel  by  moderate  adhesions         .  .  .  .  . 

Site  of  congenital  hole  in  the  Mesentery ;  Pouch  in  the  Peritoneum 
Strangulation  of  small  Intestine  throug-h  a  hole  in  the  Great  (Jniiutum 
Stenosis  of  ascending  Colon  from  the  contraction  of  Peritoneal  Adhesions  . 
Sigmoid  Flexure  showing  a  broad  membranous   Peritoneal  Band  passing 

from  the  Mesocolon  to  the  Gut 
Adhesions  forming  the  Bowel  into  a  Loop     . 
Fistula  bimneos.H,  with  formation  of  a  Loop  in  the  Ileum 
Diffused  Peritoneal  Adhesions 
The  Fossa  Duodeno-jejunalis 
Small  Hernia  into  the  Fossa  Duodtno-jejunalis 
Hernia  of  medium  size  into  the  Fossa  Duodeno-jejunalis 
Hernia  in  the  Fossa  Duodeno-jejunalis 
Hernia  into  the  Fossa  Duodeno-jejunalis 


PAGK 

11 


20 


34 

47 
48 
49 
50 
.51 


GO 
61 


G.') 
G7 
69 
89 

90 

92 

93 

9.) 

lOS 

109 

110 

111 

112 


X  INTESTINAL    OBSTRUCTION. 

PAGE 

Hernia  into  the  Foramen  of  Winslow  ....         117,  118 

The  Tntersigmoid  Fossa  .  .  .  .  .  .         119,  120 

The  Ileo-colic  Fossa     .  .  .  .  .  .  .  .121 

Ileo-ctecal  Fossa  ........     122 

Sub'Csecal  Fossa3  ........     123 

Volvulus  of  the  Sigmoid  Flexure        .'  .  .  .  .  .     127 

Volvulus  of  Lower  Ileum        .  .  .  .  .  .  .     138 

Volvulus  of  Small  Intestine    .......     140 

Vertical  and  Transverse  Sections  of  an  Intussusception        .  ,  .     141 

Intussusception  of  Jejunum    .......     142 

Intussusception  of  the  Jejunum,  one  inch  and  a  half  in  length        .  .     143 

Ileo-colic  Intussusception        .  .  .  .  .  .  .  .  147 

Intussusception  of  the  Dying  .  .  .  .  .  ,150 

Intussusception  of  descending  Colon  into  Sigmoid  Flexure  .  .     155 

Ileo-c^cal  Intussusception  with  great  swelling  of  the  Intussusceptum         .     160 
Intussusception  of  the  Ileum  .  .  .  .  .  .         161,  163 

Intussusception  of  the  Ileum.     Protrusion  of  the  Intussusceptum  through 

an  ulcerated  Opening  in  the  Sheath     .  .  ,  .  .165 

Portion  of  the   Small  Intestine,  40  inches  long,  voided  per  anum   as  a 

slough,  the  result  of  Intussusception  .....  166 
Slough  of   the  Ileum,  with  a  Meckel's  diverticulum,  passed  after    acute 

intussusception  .......     167 

Chronic  Intussusception  with  Ejjithelioma  of  the  Internal  Layer    .  .170 

Section  of  an  Intussusception  ......     171 

Vertical  Section  of  Bladder  and  Rectum,  showing  an  Intussuscep- 
tion of  Eectum  due  to  a  Growth  which  projects  from  the  Bowel 

Wall 180 

Invagination  of  a  Meckel's  Diverticulum.     The  process  projected  into  the 

Ileum  and  led  to  a  fatal  Intussusception  ....     181 

Invagination  of  the  Vermiform  Appendix      .....     182 

Double  Lateral  Invagination  .  .  .  .  .  .184 

Vulcanite  Tooth-plate,  swallowed  by  a  young  girl  and  passed  per  anum 

in  forty-two  hours.     Natural  size        .  .  .  .  .186 

A  Glass  Drop  of  a  Lustre  swallowed  by  a  boy  six  years  of  age  and  passed 

per  anum  in  fifty-two  hours.     Natural  size    .  .  .  .186 

Passage   of  an  Iron   Teaspoon,    which   had   been   swallowed   five   weeks 

previously,  from  the  Colon  through  the  Abdominal  Parietes  .     190 

Gall  Stone  impacted  in  the  Ileum       .  .  .  .  .  .193 

Obstruction  of  the  small  Intestine  bj'  a  Concretion  of  Magnesia       .  .198 

Tuberculous  Ulcer  of  a  Peyer's  Patch  in  process  of  Healing  .  .     205 

Healed  Tuberculous  Ulcer  of  the  Ileum  .....     206 

Portion   of  Jejunum  showing  two  Strictures,  the  result  of  Tuberculous 

Ulceration         ........     207 

208,  209 
.  210 
.  211 
.211 
.  212 
ure  above  a  Carcinoma 


Tuberculous  Stricture  of  the  Ileum    . 

Syphilitic  Ulcers  of  the  Colon 

Syphilitic  Stricture  of  the  Ileo-ca3cal  Valve  . 

Dysenteric  Ulcers  of  the  Lower  Part  of  the  Colon 

Stricture  of  Colon  after  Dysenteric  Ulceration 

Extensive  Follicular  Ulceration  of  the  Sigmoid  Flex 

of  the  Rectum   ........     213 

Stricture  of  the  Ueo-cjecal  Valve.    A  quill  is  passed  through  the  Stricture. 

Outside  the  Bowel  is  an  enlarged  Lymphatic  Gland  .  .  .215 

Stricture  of  the  Ileo-cajcal  Valve        ......     217 


LTST    OF   ILLUSTRATIONS.  xi 

Stenosis  due  to  in-turning  of  the  Intestinal  Wall,  the  result  cf  Mesenteric 

Gland  Disease   .  .  .  .  .  .  •  .220 

Epithelioma  of  the  Colon         .......     22;5 

Epithelioma  of  Colon.     Bird's-eye  view  of  the  Interior  of  the  Bowel  .     224 

Almost  complete  occlusion  of  the  Colon  by  a  very  small  Carcinoma  .     225 

Cylindrical  Epithelioma  of    the   Transverse   Colon,  forming   an  annular 

(Stricture  ........     226 

Congenital  Occlusion  of  the  Duodenum  by  a  Transverse  Septum     .  .     234 

Membranous  Diaphragm  in  the  Lower  Ileum  ....     230 

Congenital  Stricture  of  the  Ileum       .  .  .  .  .  .237 

Mrs.  Boyd's  case  of  Congenital  deformity  of  the  Colon  .  .         241,  242 

Idiopathic  Dilatation  of  the  Colon  .  .  ....     253 

Polypus-like  pi'ojections  from  the  Mucous  Membrane  of  the  Colon  .     260 

Small  Intestine  showing  Lymphadenoma  of  Solitary  Glands  and  Beyer's 

Batches  .  .  .  .  .  •  .      '       .     266 

Lympho-Sarcoma  of  the  Ileum  implicating  Beyer's  Batches  .  .     268 

Dilatation  of  the  Colon  above  a  Stricture  of  the  Splenic  Flexure      .  .     313 

Dilatation  of  the  Sigmoid  Flexure  above  a  Stricture  at  the  lower  end  of  the 

Flexure.  .  .  .  .  .  .  .  .314 

Dilatation  of   the  Colon   and  small    Intestine    above  a  Stricture  of  the 

Sigmoid  Flexure  .......     315 

Dilatation   of  the    Ascending  Colon  and   Ileum  above  a  Stricture  at  the 

Hepatic  Flexure  of  the  Colon  .  .  .  .  .  .316 

Dilatation  of  Coils  of  small  Intestine'  above  an  Obstruction  in  the  lower 

Ileum         .         .  .  .  .  .  .  .  ..317 

Dilated  Coils  of  small  Intestine.     "  Organ-pipe  "  arrangement  .     318 

Gall  Stone  impacted  in  the  Ileum       ...  ...     370 

Contraction  of  Colon  after  the  separation  of  an  Intussusception       .  .     387 

Diagram  showing  the  positions  in  which  fffical  masses  are  common  .     427 

Figures    to   show  the    sequestering  of   a   raw  bleeding  surface   and   the 

securing  of  a  bleeding  point  'by  stitching    .  ,  .  .     495 

Lund's  Infiator  .  .  .  .  .  .  .  .510 

Barker's  Operation  for  Intussusception  .  ...     515 


INTESTINAL  OBSTRUCTION. 


INTRODUCTION. 


Under  the  title  of  "  intestinal  obstruction "  are  included  a 
great  variety  of  conditions,  which,  although  unlike  in  character, 
have  yet  the  common  property  of  bringing  about,  mechani- 
cally, an  obstruction  to  the  passage  of  matter  along  the 
intestine.  The  obstructing  agent  may,  on  the  one  hand,  be  a 
peritoneal  adhesion,  by  means  of  which  a  loop  of  bowel  is 
snared  and  actually  strangulated ;  on  the  other  hand,  it  may 
be  represented  by  a  ring-like  growth  of  epithelioma  in  the  wall 
of  the  gut  which  very  gradually  narrows  and  perhaps  closes  its 
lumen.  The  bowel  may  be  obstructed  at  one  time  by  the 
torsion  of  a  loop  of  gut  around  an  axis  at  right  angles  to  the 
line  of  its  own  course,  as  seen  in  volvulus  of  the  sigmoid 
flexure ;  or  at  another  by  the  invagination  of  a  certain  portion 
of  the  bowel  into  the  segment  below  it  as  illustrated  by 
intussusception.  The  intestinal  canal  may  be  blocked  by  a 
gall-stone  within  its  walls  or  be  occluded  by  the  pressure  of  a 
tumour  entirely  without  its  confines. 

The  symptoms  produced  b}^  the  various  mechanical  causes 
may  be  exceedingly  acute  on  the  one  hand  or  exceedingly 
chronic  on  the  other. 

The  case  may  run  its  entire  course  from  its  commence- 
ment to  the  patient's  death  in  the  short  space  of  forty-eight 
hours,  or  the  phenomena  of  obstruction  may  persist  for  years, 
and  may  not  at  tbe  end  be  the  direct  cause  of  death. 

When  the  clinical  phenomena  come  to  reviewed,  it  is  at 
once  evident  that  too  much  prominence  must  not  be  given  to 
the  mere  circumstance  that  the  bowel  is  obstructed.  Obstruc- 
tion of  the  bowel  is  the  prominent  symptom,  but  it  is  not  the 
sole  basis  upon  which  the  great  issues  of  the  malady  depend. 
Indeed,  in  certain  acute  cases  it  is  neither  the  most  prominent 
nor  the  most  serious  of  the  manifestations. 


2  INTESTINAL    OBSTRUCTION. 

In  acute  intussusception  the  disease  may  run  its  course 
and  end  in  death  without  there  having  been  produced  a 
definite  obstruction  in  the  kimen  of  the  bowel. 

The  duration  of  the  obstruction  to  the  passage  of  the 
faeces  is  also  not  an  inevitable  criterion  of  the  gravity  of  the 
case.  A  loop  of  gut  may  be  strangulated  within  the  abdomen 
and  death  may  follow  within  a  week,  no  material  passing 
through  the  alimentary  canal  in  the  meanwhile.  On  the 
other  hand,  the  colon  may  be  actually  plugged  with  a 
hardened  mass  of  faecal  matter,  and  while  no  trace  of  a 
motion  may  be  passed  for  four  or  more  weeks,  the  patient 
may  yet  make  a  good  recovery.  In  the  acute  cases,  as 
Avill  be  immediately  shown,  the  actual  fact  that  the  bowel  is 
obstructed  is  comparatively  unimportant.  The  obstruction, 
gttd  obstruction,  does  not  produce  the  more  urgent  symptoms, 
nor  does  it  act  as  the  direct,  nor,  indeed,  as  the  prominent 
cause  of  death.  As  an  abstract  proposition,  it  may  be  stated 
that  obstruction  of  the  lumen  of  the  bowel  for  a  period  of  a 
week,  or  even  more,  is  not  in  itself — all  other  circumstances 
being  disregarded — a  condition  which  need  cause  death  or 
even  distressing  inconvenience. 

If  the  clinical  phases  of  quite  acute  and  quite  chronic 
forms  of  intestinal  obstruction  be  studied  comparatively,  the 
following  general  features  become  evident : — 

In  the  very  acute  cases,  as  illustrated  by  strangulation  by 
a  band,  the  grave  initial  symptoms  obviously  do  in  no  way 
depend  upon  the  undoubted  fact  that  the  bowel  is  obstructed. 

Time  must  elapse  before  the  mere  obstruction  can  produce 
phenomena  of  discomfort. 

When  a  loop  of  gut  is  snared  by  a  band,  the  initial 
symptoms  are  due  solely  to  a  sudden  and  severe  injury  to  the 
peritoneum  and  to  the  numerous  important  nerves  of  the 
implicated  part. 

These  symptoms,  which  are  mainly  those  of  intense 
abdominal  pain,  with  collapse  and  usually  with  vomiting,  are 
by  no  means  peculiar  to  intestinal  obstruction,  but  are  common 
rather  to  nearly  all  acute  lesions  within  the  abdomen.  They 
have  been  described  collectively  under  the  title  of  "  peri- 
tonism." Such  symptoms  may  attend  the  passing  of  a  gall- 
stone and  the  twisting  of  the  pedicle  of  an  ovarian  tumour, 
and,  in  fact,  both  these  conditions  have  during  the  initial 
stages  been  mistaken  for  acute  intestinal  obstruction.  The 
symptoms  which  depend  upon  the  injury  to  the  bowel,  in 
distinction  to  the  mere  obstruction  of  its  lumen,  remain  prom- 
inent for  some  little  time,  and,  other  things  being  equal, 
depend   in   their    degree   of    severity   upon    the   amount   of 


INTRODUCTION.  3 

intestine  involved,  the  tightness  of  the  strangulation,  and 
the  nearness  of  the  loop  to  the  stomach. 

Certain  phenomena  which  follow  are  due  undoubtedly 
to  the  actual  obstruction,  and  prominent  among  them 
nuist  be  placed  the  constipation,  the  incessant  vomiting  and 
the  distension  of  the  belly.  This  latter  symptom,  however, 
is  not  solel}'  dependent  upon  mere  accumulation  of  matter 
in  the  gut  above  the  narrowed  part,  as  will  be  explained  sub- 
sequently (page  13).  The  final  sj'mptoms  of  acute  intestinal 
obstruction — the  symptoms  which  precede  death — are  again 
not  so  much  those  due  directly  to  occlusion  of  the  lumen 
of  the  bowel  as  those  depending  upon  septic  infection  of 
the  whole  body  from  the  disordered  intestine. 

The  subjects  of  acute  intestinal  obstruction  die  for  the 
most  part  with  the  phenomena  of  septic  poisoning,  and  if 
a  certain  stage  has  been  passed  the  mere  relieving  of  the 
obstruction  does  not  save  life. 

In  chronic  intestinal  obstruction,  as  illustrated  by  the 
closure  of  the  colon  by  a  ring  of  malignant  growth,  the 
phenomena  are  much  more  distinctly  the  direct  outcome 
of  actual  obstruction.  The  bowel  becomes  filled  up,  but 
so  long  as  the  obstruction  is  not  complete  and  a  little 
matter  can  escape  from  time  to  time,  the  distress  occasioned 
may  be  quite  slight.  Two  results  follow.  The  irritation, 
septic  and  mechanical,  of  the  long-retained  faeces  leads  to 
catarrh,  and  the  expression  of  that  takes  the  form  of  a 
spurious  diarrhoea.  At  the  same  time  the  bowel  becomes 
hypertrophied  in  its  persistent  attempts  to  empty  itself 
of  its  contents,  and  enlarged  coils  are  usually  seen  and 
felt  in  movement  through  the  walls  of  the  abdomen.  A 
certain  degree  of  septic  intoxication  is  not  uncommon 
even  in  the  early  stages  of  the  disease,  and  the  ending  is 
often  by  acute  obstruction,  or  by  the  septic  poisoning 
which  follows  upon  peritonitis. 

The  infection  in  those  forms  of  peritonitis  which  depend 
upon  intestinal  obstruction  comes  from  the  bowel,  and  a 
conspicuous  element  in  the  surgical  treatment  of  obstruc- 
tion is  not  only  to  relieve  the  actual  mechanical  cause  of 
the  trouble  (as  by  dividing  a  band),  but  to  relieve  also  the 
engorged  bowel  by  emptying  it  of  its  putrid  contents. 


CLASSIFICATION 

The  circmnstances  which  bring  about   an  obstruction  ol 
the  bowel  are — as  has  just  been  stated — numerous  and  varied 


4  INTESTINAL    OBSTRUCTION. 

.iiid  no  one  scheme  of  classification  will  meet  all  the  con- 
ditions upon  which  a  consideration  of  the  subject  may 
be  based. 

Two  principal  methods  of  classification  at  once  suggest 
themselves;  first,  that  based  upon  the  onechanical  conditions 
which  cause  the  obstruction;  and,  second,  that  founded  upon 
the  clinical  manifestations  which  that  obstruction  may  pro- 
duce. The  first  plan  of  classification  will  be  followed  in 
dealing  with  the  morbid  anatomy  and.  pathology  of  intes- 
tinal obstruction  ;  and  the  second  in  discussing  the  sy7nj)toiiis 
with  which  the  trouble  is  attended. 


1.  The  Classification  of  Intestinal  Obstruction  accord- 
ixci  to  the  Mechanical  Conditions  producing  it. 

1.  Strangulation.     The  Eowel  is  snared.        Exanvples  :    Strangula- 

tion by  bands  or 
through  apei'tures. 
Hernite. 

2.  Torsion.  The  Bowel  is  twisted.       Examples  :     Volvulus. 

Obstruction  by  kink- 
ing. 

3.  Invagination.       The  Bowel  is  invagin-    Example:  Intussuscep- 

ated.  tion. 

4.  Obturation.  The  Bowel  is  blocked.       Examj^les:  Ohsivncixon 

due  to  foreign  bodies, 
gall-stones,  etc.  Fte- 
cal  accumulation. 

5.  Stenosis.  The  Bowel  is  narrowed.     Examples  :    (a)  Stric- 

tures. (6)  Compres- 
sion from  without. 


In  the  first  four  of  the  above  classified  varieties  it  is  to 
be  noted  that  there  is  no  primary  or  essential  change 
in  the  intestine  itself,  so  far  at  least  as  its  actual  wall  is 
concerned. 

In  the  first  variety  a  normal  loop  of  bowel  is  snared 
and  strangulated,  as  seen  in  the  common  circumstance  of 
a  strangulated  hernia.  The  strangulating  agent  may  be  a 
peritoneal  band  or  adhesion,  or  an  adherent  Meckel's  diver- 
ticulum, or  the  margins  of  the  foramen  of  Winslow,  or  of  a 
slit  in  the  mesentery. 

In  the  second  variety  a  loop  of  bowel,  together  Avith  its 
mesentery  or  mesocolon,  is  twisted  upon  itself,  the  con- 
dition being  most  commonly  illustrated  by  volvulus  of  the 
sigmoid  flexure.  This  subdivision  will  also  include  the 
occlusion  of   the  bowel  by  kinking  or  the    bending  of  the 


INTRODUCTION.  5 

gut  acutely  upon  itself,  just  as  a  thin  tube  of  indiarubbov 
may  be  kinked. 

In  the  third  form  a  certain  part  of  the  intestine  is  invagin- 
ated  into  the  part  immediately  continuous  with  it.  It  is  true 
that  in  this  variety  changes  rapidly  occur  in  the  wall  of  the 
invaginated  portion  of  the  bowel,  and  that  these  changes  play 
a  very  important  part  in  the  production  of  obstructive  symp- 
toms. Such  changes  are,  however,  secondary  and,  in  a  limited 
sense,  accidental. 

In  the  fourth  variety  the  lumen  of  the  bowel  is  simply 
blocked,  the  obstructing  agent  having  no  structural  con- 
nection with  the  intestinal  wall.  The  fifth  variety  of 
intestinal  obstruction — that  known  as  stenosis — calls  for 
more  detailed  consideration.  In  this  mechanical  form  the 
lumen  of  the  bowel  is  narrowed,  but  such  narrowing  may  be 
due  to  two  perfectly  distinct  causes.  In  the  first  of  these 
two  kinds  the  stenosis  is  due  to  changes  in  the  bowel  wall 
itself.  In  that  wall  there  is  a  growth  or  a  cicatrix  whereby 
the  lumen  is  narrowed  and  obstruction  symptoms  are 
produced.  This  sub-variety  is  iUustrated  by  the  many  forms 
of  stricture  which  may  be  due  to  a  malignant  growth  of  the 
gut  on  the  one  hand  or  to  the  contracting  cicatrix  of  a  non- 
malignant  ulcer  of  the  bowel  on  the  other.  In  the  second  of 
the  two  forms  of  stenosis  the  lumen  of  the  bowel  is  narrowed 
by  changes  which  are  outside  and  beyond  the  actual  intestinal 
wall  This  kind  is  illustrated  by  cases  in  which  the  bowel  is 
compressed  by  a  tumour- — such  as  a  cancerous  uterus — out- 
side the  canal  or  by  contracting  peritoneal  adhesions,  or  by  a 
diffuse  growth  which  has  arisen  beyond  the  bowel  but  has 
grown  around  it  and  compressed  it. 

As  a  further  amplification  of  the  table  above  given,  a 
classification  niay  be  based  upon  the  degree  of  the  obstrue- 
tion,  for  it  is  evident  that  cases  of  intestinal  blocking  may 
be  divided  into  those  in  which  the  lumen  of  the  tube  is 
completely  occluded  and  those  in  which  the  closure  is  in- 
complete, and  the  passage  is  only  imperfectly  obstructed. 

Such  a  classification  arranges  itself  as  follows: — 

1-  Occhision.  Closure  of  Lumeji  of  gut  complete.  Passage  of 
contents  impossible.  Illustrated  by  ^^1)  .strangulation  and 
(2)  torsion. 

2.  Obstruction.  Closure  of  lumen  of  gut  incomplete.  Passage  of 
contents  difficult.  Illustrated  by  (3)  invagination,  (4)  obtura- 
tion, and  (5)  stenosis. 

It  is  unnecessary  to  state  that  considerable  differences 
both  as  regards  symptoms  and  prognosis,  exist  between  the 


6  INTESTINAL    OBSTIiUCTION 

"cases  in  which  the  liunen  of  the  howel  is  absokitely  occkidcd 
and  thos-e  in  Avhich  the  passage  is  merely  obstructed,  such 
obstruction  beino-  incomplete. 

Finally  it  will  be  found  convenient  when  dealing  with 
the  morbid  aTioiomy  of  intestmal  ohstruction  to  arrange 
the  anatomical  varieties  of  the  affection  in  the  following 
order : — 

1.  Strangulation  by  bauds  and  through  ajjcrtures,  including  "  internal 

heruiiB." 

2.  Volvulus. 

3    Intussusception. 

4.  Obstruction  due  to  foreign  bodies,  gall-stones,  and  enteroliths. 

5.  Stricture. 

6.  Obstruction  due  to  tumours  growing  from  the  bowel  wall. 

7.  Obstruction   due  to  the  pressure   ot  tumours,   etc.,   external   to 

the  bowel. 

8.  FfBcal  accumulation. 

This  method  of  classification  will  be  observed  in  the 
sections  which  follow  on  the  pathology  and  morbid  anatomy 
of  intestinal  obstruction. 


2.  The    Classification    of    Intestinal    Obstruction    ac- 
cording TO  THE  Clinical  Manifestations  pr(.)duced. 

1.  Acute  obstruction. 

2.  Chronic  obstruction. 

3.  Cases  in   which   symptoms   of  acute   obstruction   supervene   on 

those  indicative  of  chronic  obstruction. 

The  acute  cases  are  of  so  severe  a  type  that  the  majority 
die,  if  unrelieved,  in  some  six  or  seven  days.  Examples  of 
this  form  of  obstruction  are  provided  by  cases  of  strangula- 
tion by  bands,  by  volvulus,  by  acute  intussusception,  and 
by  abrupt  blocking  of  the  bowel  by  gall-stones  or  foreign 
bodies. 

Chronic  obstruction,  on  the  other  hand,  may  pui'sue  a 
course  extending  over  months  or  even  years.  It  is  illustrated 
by  tke  various  form  of  stenosis  of  the  bowel,  by  chronic 
intussusception,  and  by  fiecal  accumulation. 

The  cases  which  come  under  the  third  category  are 
those  in  which  the  syinptoms  of  chronic  obstruction  are 
suddenly  interrupted  by  the  phenomena  of  acute  occlu- 
sion of  tke  bowel.  This  A^ariety  is  illustrated,  in  case  of 
stricture  of  tke  intestine  in  which  the  narroAved  part  of 
the  gut  becomes  suddenly  occluded,  by  bending  or  kink- 
ing of  the   bowel,    or    by    the    blocking    of    its    lumen    by 


INTliODUGTION.  7 

a  foreign  body  which  has  been  swallowed,  or  by  a  Uiass  of 
undigested  food. 

liELATIVE  FREQUENCY  OF   THE  VARIOUS  FORMS. 

Precise  information  upon  this  point  is  not  very  easy  to 
obtain.  Statistics  based  upon  post-mortem  records  must 
obviousl}^  be  incomplete,  as  only  a  proportion  of  the  examples 
of  intestinal  obstruction  are  fatal. 

Hospital  records  deal  for  the  most  part  with  the  severer 
forms  of  the  trouble,  although  it  must  be  acknowledged 
that  such  examples  of  intestinal  obstruction  as  are  not  serious 
or  severe  are  few  in  number.  Tables  based  upon  the 
published  records  of  individual  cases  are  the  least  suited  of  all 
for  the  present  purpose.  Such  records  are  largely  concerned 
with  instances  of  successful  treatment  on  the  one  hand,  and 
with  pathological  surprises  and  anatomical  curiosities  on  the 
other. 

An  examination  of  the  records  of  the  London  Hospital 
shows  that  the  cases  ascribed  to  faecal  accumulation  are  the 
most  numerous ;  then  come  cases  of  stricture  of  the  large 
intestine,  then  intussusception,  and  next  in  order  of  fre- 
quency strangulation  by  bands.  Obstruction  due  to  tumours 
external  to  the  bowel  ranks  next ;  then  follows  the  blocking 
of  the  gut  by  gall-stones  or  foreign  bodies  ;  while  the  remain- 
ing forms  of  intestinal  obstruction  may  be  spoken  of  as  rare. 

THE   PORTION    OF   BOWEL   INVOLVED. 

Strangulation  by  hands  most  commonly  involves  the  small 
intestine.  The  small  intestine  also  is  most  often  concerned  in 
internal  hernias.  Volvulus  is  most  frequent  in  the  sigmoid 
flexure,  and  is,  indeed,  rare  elsewhere.  Intussusception  has 
its  most  usual  seat  in  the  ileo-Cfecal  segment  of  the  bowel. 
Strictures  of  all  kinds  are  more  conmion  in  the  colon  than  in 
the  lesser  intestine.  They  are  more  common  in  the  lower 
segments  of  the  colon  than  in  the  upper.  Obstruction  due  to 
pressure  from  without  may  be  met  with  in  any  part  of  the 
canal,  but  more  usually  concerns  the  large  intestine  as  being 
the  less  movable,  and  especially  the  rectum  and  sigmoid 
flexure  from  their  position  with  reference  to  the  pelvis. 
Foreign  bodies  often  lodge  in  the  lower  ileum  and  in  the 
cfecuni,  and  gall-stones  are  apt  to  become  impacted  in  the 
jejunum  or  upper  ileum.  Fcecal  accumulation  of  necessity 
is  met  with  only  in  the  colon,  and  often  in  the  caecum  and 
sigmoid  flexure,  or  in  the  hepatic  or  splenic  flexures. 


8  INTESTINAL    OBSTRUCTION. 

THE   QUESTION   OF   SEX   AND  AGE. 

Strangulation  by  hands  and  through  apertures  is  a  little 
more  coirimon  in  males  than  in  females,  is  met  with  mostly 
in  young  adults,  and  is  rare  after  forty.  It  is  still  rarer  before 
ten.  Internal  hernice  have  been  shown  to  be  more  common 
in  males,  and  the  greater  number  of  the  recorded  cases  have 
fallen  between  the  ages  of  twenty- live  and  forty-five.  Vol- 
vulus of  the  sigmoid  flexure  is  about  four  times  more 
common  in  men  than  in  women.  It  is  most  usual  between 
forty  and  sixty,  and  is,  indeed,  rare  before  forty.  Acute 
intussusception  is  a  little  more  often  met  with  in  the  male 
sex.  It  mostly  attacks  the  young.  Fifty  per  cent,  of  the 
cases  are  under  the  age  of  ten  years.  Strictures  are  equally 
coirtmon  in  the  two  sexes.  The  non-mahgnant  occur  about 
early  middle  life.  The  cancerous  stricture  is  rare  before  forty. 
(Certain  strictures  of  the  intestine  are  congenital.  Obstruction 
due  to  tumours  external  to  the  bowel  is  obviously  more 
common  in  women,  and  in  adults  of  that  sex.  Obstruction 
due  to  impacted  gall-stones  is  more  usual  in  females  than 
in  males,  and  the  average  age  lalls  between  tilty  and  sixty-five. 
Fcecal  accwmulation  occurs  with  greater  frequency  in  women 
than  in  men.  It  is  most  common  in  adults  and  the  aged, 
and  is,  as  may  be  imagined,  not  infrequent  in  the  insane  and 
hystericaL 


PART    I. 
PATHOLOGY    AND    MOEBID    ANATOMY. 


CHAPTER    I. 

GENERAL    PATHOLOGY   OF    INTESTINAL   OBSTRUCTION. 

Ix  this  section  of  the  work  the  subject  will  be  dealt  with  in 
the  following  order  : 

The  General  Pathology  of  Occlusion  of  the  Bowel. 
The  General  Pathology  of  Obstruction  of  the  Bowel. 
The  Morbid  Anatomy  of  Particular  Forms  of  Intestinal 
Obstruction. 

The  General  Pathology  of  Occlusion  of  the  Bowel. — ■ 
In  the  variety  of  intestinal  obstruction  now  to  be  considered 
the  closure  of  the  lumen  of  the  gut  is  complete,  the  passage 
of  intestinal  contents  is  impossible,  and,  in  fact,  the  obstruc- 
tion is  absolute.  This  variety  is  illustrated  hj  the  many 
forms  of  strangulation  of  the  bowel  and  by  volvulus.  The 
bowel  concerned  is,  at  the  time  of  the  accident  which  occludes 
it,  normal ;  the  occlusion  is  sudden,  and  is  practically  complete 
from  the  first ;  the  segment  of  intestine  involved  is  usually  the 
small  intestine,  and  when  the  colon  is  implicated  the  lesion  most 
commonly  takes  the  form  of  volvidus.  As  a  typical  example 
of  the  condition  may  be  selected  the  strangulation  of  a  loop 
of  ileum  beneath  an  adherent  peritoneal  adhesion.  The  small 
intestine,  by  its  mobility,  by  the  smoothness  of  its  surface  and 
by  its  relatively  small  girth,  is  much  more  apt  to  be  snared  by 
a  band  than  is  a  loop  of  the  colon.  The  wall  of  the  lesser 
bowel  is  comparatively  thin  and  frail,  and  the  effects  ot 
strangulation  are  very  soon  made  manifest  in  its  deHcate 
tissues.  The  nerve  supply  of  the  lesser  bowel  is  elaborate,  and 
in  close  association  with  the  great  nerve  centres  of  the 
abdomen.  The  colon,  on  the  other  hand,  has  stouter  walls, 
its  sacculi  and  the  appendices  epiploicse  may  offer  some 
obstacle  to  the  smooth  gliding  of  a  loop  beneath  a  band,  and, 
if  lightly  snared,  the  disposition  of  its  muscular  layers  would 


10  GENERAL    PATHOLOGY. 

facilitate  its  escape.  The  colon  is  cast  in  a  coarser  mould 
than  is  the  lesser  bowel.  Its  physiological  purpose  is  less 
important.  It  is,  indeed,  little  more  than  a  receptacle  for 
debris  discharg-ed  from  the  intestine  above  it ;  and,  as  one 
might  expect,  its  nervous  organisation  is  not  so  elaborate,  nor 
is  its  connection  with  the  great  nerve  centres  of  the  abdomen 
so  intimate  and  direct  as  it  is  in  the  case  of  the  jejunum 
and  ileum. 

It  thus  happens  that  the  phenomena  of  strangulation  are 
much  more  pronounced,  both  as  regards  the  pathological  and 
clinical  aspects,  when  the  small  intestine  is  concerned  than 
they  are  when  the  segment  snared  belongs  to  the  colon. 
Other  things  being  equal,  the  strangulation  of  six  inches 
of  ileum  is  a  much  more  severe  lesion  than  is  a  corresponding 
strangulation  of  six  inches  of  the  sigmoid  flexure.  It  is  not 
only  much  more  severe,  in  the  sense  of  being  more  clearly 
marked  in  all  the  phenomena  produced,  but  it  is  in  a 
corresponding  degree  more  serious. 

If  a  strangulation  of  the  colon  is  to  produce  manifestations 
equal  in  degree  with  those  which  attend  strangulation  of  the 
lesser  bowel  then  a  greater  extent  of  intestine  should  be 
involved.  When  a  considerable  segment  of  the  colon  is 
implicated,  as  in  volvulus  of  the  sigmoid  flexure,  the 
phenomena  are  verj^  acute,  and  are  quite  on  a  par  with  the 
efl'ects  attending  a  strangulation  of  the  lesser  intestine.  In 
such  instances  what  the  colon  has  lacked  in  fineness  and 
sensitiveness  of  structure  it  has  made  up  in  the  extent  of 
tissue  involved. 

The  changes  brought  about  in  the  bowel  by  absolute 
occlusion  of  the  kind  now  under  consideration  are  identical 
with  those  which  attend  a  strangulated  hernia. 

The  difference  between  the  intestine  above  the  obstruction 
and  that  below  is  very  sharply  marked. 

Lavater,  in  graphically  describing  the  effects  of  strangu- 
lation, observed  that  the  bowel  above  the  obstruction  grows 
red,  the  bowel  below  it  grows  white,  and  the  coil  involved 
grows  livid  and  purple. 

The  intestine  above  the  seat  of  strangulation  is  dis- 
tended and  tilled  with  gas  and  fluid.  The  degree  of  dis- 
tension varies,  but  the  bowel  may  be  often  found  to  be 
twice  or  even  three  times  its  normal  size.  The  distended 
gut  is  a  dull  red.  This  tint  is  due  to  a  certain  degree  of 
congestion,  and  upon  the  serous  surface  the  dilated  blood- 
vessels form  a  dense  tracery.  The  dilated  gut  may  be  actually 
much  thickened  by  oedema,  but  it  never  shows  any  traces 
of  hypertrophy.     Indeed,  if  there   be  no  oedema  the  bowel 


STRANGULATION    OF    THE    BOWEL.  ]l 

Avail  will  be  found  to  be  actually  thinned,  and  this  condition 
can  be  often  seen  in  coils  which  are  at  some  distance  from 
the  obstruction,  but  Avliich  have  nevertheless  taken  part  in  the 
general  distension.     These  thinned  coils  will  be  pale. 

The  mucous  membrane  of  the  gut  near  to  the  occlusion 
is  found  to  be  swollen  with  (sdema,  aud  of  a  deep  red 
colour.  Superficial  erosions  are  not  infrequent  in  the  gut 
just  above  the  obstruction,  but  the  ulcers  which  are  so 
common,  and  indeed  so  usual,  in  the  intestine  above  a 
stenosis  are  in  this  instance  absent. 

Now  and  then  gangrenous  patches  are  found  in  the  wall 
of  the  intestine  which  is  immediately  above  the  involved 
loop.  This  condition  is,  however,  only  found  in  cases  ot 
strangulation  which  have  been  of  imusually  long  duration. 
In  no  circumstances  is  it  common ;  in  internal  strangu- 
lation it  is  quite  rare,  and  the  examples  met  with  are 
usually  provided  b}''  cases  of  strangulated  hernia. 

The  intestine  below  the  strangulation  is  pale,  con- 
tracted, and  empty  and  accords  with  the  condition  of  the 
"  starvation  intestine." 

As  a  rule,  the  contrast  between  the  bowel  above  the 
obstruction  and  that  below  is .  very  marked,  but  now  and 
then  I  have  seen  quite  a  definite  deoree  of  congestion  in 
the  bowel  immediately  below  the  implicated  coil. 

It  may  be  mentioned  in  this  connection  that  in  certain 
cases  of  strangulated  hernia  the  bowel  below  the  stricture 
has  been  the  seat  of  acute  enteritis. 

The  strangulated  loop  will  exhibit  those  changes  which 
have  been  so  carefully  observed  and  so  elaborately  described 
in  connection  with  strangulated  hernia.  The  strangled  loop 
becomes  congested  and  oedematous.  As  the  engorgement 
increases  the  colour  changes  from  a  dark  blue  to  a  reddish 
blue,  and  thence  to  a  chocolate  or  a  port-wine  colour,  and 
finally,  in  extreme  cases,  to  black.  These  colour  changes, 
and,  indeed,  all  the  phenomena  of  strangulation,  are  more 
marked  in  instances  in  which  a  small  loop  is  well  snared 
than  in  cases  attended  Avith  the  strangulation  of  a  large 
coil.  In  the  earlier  phases  of  strangulation  the  individual 
vessels  can  be  seen  upon  the  bowel  Avail,  but  as  time  passes 
the  outline  of  the  separate  vessels  is  lost. 

The  snared  boAvel  preserves  for  a  Avhile  its  normal 
smooth  and  lustrous  surface,  l.'Ut  this  is  soon  replaced  by 
a  surface  Avhich  is  dull,  cloudy,  and  sticky.  Finally,  upon 
the  serous  membrane  will  be  apparent  the  effects  of  local 
peritonitis.  Noav  and  then  quite  an  extensive  layer  of 
coagulated  fibrine,  irregularly  disposed,  may  be  found  upon 


12  GENERAL    PATHOLOGY. 

the  strangled  coil.  The  snared  bowel  is  tense,  owing  to  the 
infiltration  of  its  coats,  and  the  distension  of  its  cavity  with 
gas.     To  the  touch  it  feels  thick  and  fleshy. 

Within  the  loop  will  be  found,  as  a  rule,  only  a  little 
thin,  dirty-looking  fluid,  which  in  an  instance  or  two  may 
be  stained  with  blood.  Clots  of  blood  have  been  found 
within  the  loop. 

Finally — if  the  patient  live  long  enough — the  bowel 
becomes  gangrenous.  It  loses  its  elasticity,  and  feels  soft 
and  doughy.  The  gangrenous  parts  may  be  black  in  colour, 
but  are  more  often  ashen  grey. 

The  extent  of  the  gangrene  shows  considerable  variation, 
from  a  mere  patch  to  the  destruction  of  a  considerable  loop 
of  gut.  At  a  gangrenous  point  the  gut  may  become  per- 
forated 

S|3eeial  stress  comes  upon  the  bowel  at  the  line  of  the 
actual  constriction,  and  changes  follow  which  are  identical 
with  those  met  with  in  strangulated  hernia.  Linear  gangrene 
is  very  apt  to  occur  at  this  line.  Under  the  influence  of 
pressure  the  mucous  membrane  perishes  flrst,  then  the 
muscular  coat,  and  last  of  all  the  serous  tunic.  The  effect 
of  the  strangulation  is,  as  a  rule,  more  marked  in  that  end  of 
the  loop  which  is  continuous  with  the  bowel  above  the  line 
of  constriction- 
It  is  by  no  means  alwa3^s  easy  to  tell  whether  the 
strangulated  gut  is  still  living  or  is  dead ;  it  is  still  more 
ditiicult  to  foretell  that,  although  damaged,  it  will  recover. 
If  the  covering  of  the  bowel  retain  its  lustre,  if  the  vessels 
in  its  walls  can  be  seen  to  empty  and  I'etill  on  stroking,  and 
if  the  gut  bleeds  when  pricked,  it  is  evidently  still  living. 
On  the  other  hand,  the  lustre  of  the  serous  coat  may  soon 
be  destroyed  by  inflammation,  the  individual  vessels  may  be 
lost  to  view,  and  an  extravasation  of  blood  may  have  taken 
place  at  the  point  under  examination.  Mere  depth  of  colour 
IS  not  an  infallible  sign  of  the  state  of  the  gut.  A  loop 
almost  black  in  colour  may  undergo  complete  recovery,  while 
a  like  loop  that  is  merely  a  bluish  purple  may  give  way  alter 
it  has  been  liberated. 

The  interpretation  of  the  varied  changes  found  in  the 
intestine  after  occlusion  of  its  lumen  has  been  the  subject  of 
much  discussion.  It  cannot  yet  be  said  that  the  pathology  of 
the  condition  is  to  be  explained  in  a  manner  which  is  entirely 
satisfactory. 

The  causes  of  the  changes  found  in  the  wall  of  the 
strangulated  loop  are  not  ditiicult  to  explain.  It  has  been 
long  ago  pointed  out  that  distension  of  a  loop  of  intestine  is 


PATHOLOGY    OF   METEORISM.  13 

attended  with  such  a  loss  of  its  contractile  ability  as  soon 
to  reach  the  point  of  paralysis.  It  is  not  difficult  to 
understand  that  the  distended  bowel  might  become  congested 
owing  to  gross  disturbance  of  its  circulation,  but,  following 
upon  this,  come  definite  difficulties  in  the  way  of  explaining 
the  distension  which  is  so  much  in  evidence. 

Thus  it  happens  that  most  of  the  interest  attaching  to 
this  subject  has  centred  around  the  pathology  of  meteorism. 

It  was  assumed  in  a  general  way  that  meteorism  was  due 
to  the  circumstance  that  gas  accumulated  in  the  bowel  and 
that  this  accumulation  depended  upon  the  simple  fact  that 
the  bowel  was  blocked  up.  The  conclusion  which  must 
follow  from  this  assumption  is  that  the  degree  of  meteorism 
in  intestinal  obstruction  must  depend  in  the  main  upon  the 
seat  of  the  blocking  and  that  the  nearer  this  be  to  the  anus 
the  greater  must  be  the  distension  of  the  belly. 

Clinical  facts,  however,  do  not  quite  support  this  con- 
clusion, and  but  very  little  examination  into  the  matter  from 
a  clinical  standpoint  makes  it  evident  that  the  explanation 
is  not  entirely  satisfactory. 

A  good  deal  of  light  has  been  thrown  upon  this  subject 
by  certain  experiments  upon  animals. 

The  most  valuable  series  of  experiments  was  performed  by 
Kader,^"  and  as  his  work  deals  with  many  phases  of  the  pre- 
sent subject  it  is  well  that  it  should  be  considered  in  some 
detail. 

Kader's  experiments  are  divided  into  four  groups. 

Group  I.  A  loop  of  intestine  was  strangulated  together 
with  its  mesentery.  The  bowel  was  therefore  completely 
occluded  in  two  places  and  the  circulation  of  blood  in  its 
walls  was  arrested.  The  lesion  was  intended  to  imitate  acute 
strangulation  by  a  band. 

Group  II.  A  loop  of  intestine  was  occluded  at  two  points 
some  little  distance  from  one  another.  This  was  so  done  as 
not  to  disturb  the  circulation  of  blood  in  the  isolated  loop. 
These  experiments  imitated  the  conditions  attending  stricture 
of  the  bowel  and  occlusion  by  foreign  bodies,  etc. 

Group  III.  The  bowel  was  left  untouched,  but  the  mes- 
entery of  a  certain  loop  was  so  ligatured  that  the  circulation 
in  that  loop  was  arrested,  the  lumen  of  the  bowel  being  per- 
fectly free.  Here  were  reproduced  the  conditions  attending 
thrombosis  of  the  mesenteric  vessels. 

Group  IV.  The  mesentery  of  a  certain  loop  of  intestine 
was  ligatured  as  in  Group  III.  The  bowel  immediately  above 
the  loop  thus  deprived  of  blood  was  occluded  so  that  no  fa3cal 

*  Beutsch.  Zeitsch.filr  Chir.,  1891,  p.  57. 


u 


GENERAL    PATHOLOGY. 


matter  passing  from  above  could  enter  the  section  of  intestine 
attached  to  the  damaged  mesentery.     (See  Fig.  1.) 

The  changes  observed  in  the  intestine  as  the  results  of  the 
lesions  just  enumerated  are  as  follows  : — 

Group  I.  When  the  strangulating  cord  is  not  too  tightly 
drawn  the  loop  of  bowel  presents  at  first  the  condition  of 
venous  hypertemia  and  then  of  venous  stasis.  The  bowel  wall 
becomes   oederaatous   and   often    presents    extravasations    of 

blood.  A  serous 
exudation        takes 

f)lace  into  the 
umen  of  the  gut. 
If  the  strangu- 
lating cord  be 
drawn  as  tightly 
as  possible  the  loop 
becomes  pale  and 
then  cyanotic. 

As  the  blood 
supply  is  abruptly 
and  entirely  cut  off 
there  is  little  or  no 
cedema,  no  extra- 
vasation and  no 
exudation  into  the 
lumen  of  the  bowel. 
In  any  case  the 
coil  of  strangulated 
bowel  soon  be- 
comes paralysed. 
Gas  develops  in 
this  coil  and  dis- 
tends it.  If  the  loop  be  apparently  empty  still  gas  develops, 
but  if  the  gut  contain  fsecal  matter  then  the  formation  of  gas 
is  more  copious.  The  vessels  of  the  strangulated  mesentery 
become  thrombosed.  The  bowel  becomes  gangrenous  in  whole 
or  in  part.  Perforation  may  take  the  form  of  a  large  and  very 
evident  hole,  or  there  may  be  numerous  minute  capillary 
)>erforations  which  may  easily  be  overlooked  but  which  allow 
the  escape  of  gas.  The  bowel  above  and  below  the  strangu- 
lated coil  at  first  contracts  for  a  few  moments  as  if  from  cramp. 
The  bowel  above  then  becomes  distended.  This  distension  takes 
place  much  slower  than  in  the  strangulated  loop.  The  bowel 
becomes  less  and  less  contractile,  although  not  actually  para- 
Ivsed,  and  its  mucous  membrane  becomes  congested  and  its 
lumen  occupied  by  stagnant  faeces.     The  intestine  below  the 


Group  [I[. 


Tig.    1. 


Groui)  IV. 

-Kader's    experiments    to    demonstrate    the 
production  of  Meteorism. 


KADER'S    EXPERIMENTS.  15 

damaged  part  remains  empty  and  to  some  extent  contracted. 
Experiments  by  others  have  shown  that  the  wall,  of  the 
damaged  bowel  very  soon  permits  bacteria  to  escape  and 
reach  the  peritoneum  and  that  such  escape  takes  place  long 
before  there  is  any  suspicion  of  perforation.  As  a  result  early 
peritonitis  is  induced,  and  this  deepens  the  paralysis  of  the 
bowel  and  so  favours  an  increase  ot  the  meteorism. 

Group  II.  If  the  isolated  loop  contains  no:  intestinal 
matter  very  little  gas  is  developed  in  it.  If  it  does  contain 
such  matter  some  gas  is  formed,  but  it  is  small  in  amount  and 
does  not  lead  to  distension  of  the  loop.  The  contractility  of 
the  walls  of  the  loop  is  only  very  slightly  diminished,  and  no 
gross  changes — such  as  just  described — take  place  in  the 
tissues  of  the  bowel.  The  intestine  above  the  isolated  loop 
becomes  more  distended  than  is  the  loop  itself  and  its  con- 
tractility becomes  a  little  diminished.  The  bowel  below 
remains  unchanged  or  becomes  somewhat  contracted. 

Group  III.  Marked  changes  take  place  in  the  segment 
of  intestine  which  is  deprived  of  blood.  Its  contractility 
diminishes  to  the  point  of  paralj^sis.  Its  walls  become 
thickened  and  oedematous,  and  exudation  takes  place  into 
the  lumen  of  the  tube  Much  gas  develops  in  the  affected 
segment,  and  in  time  the  bowel  exhibits  the  phenomena  of 
gangrene. 

Group  IV.  Like  changes  occur  to  those  just  described. 
The  damaged  bowel  becomes  the  seat  of  local  meteorism 
in  spite  of  the  fact  that  nothing  can  enter  it  from  above, 
and  it  can  empty  itself  freely  below.  The  intestine  above 
the  occlusion  in  the  tube  becomes  more  or  less  distended. 

From  these  experiments  it  will  be  evident  that  the  gas 
which  causes  the  meteorism  is  the  product  of  the  decom- 
position of  the  intestinal  contents,  and  that  its  amount  is 
to  some  extent  determined  by  the  quantity  of  matter  in 
the  bowel  at  the  time.  Inasmuch  as  absorption  from  the 
bowel  is  arrested  when  obstruction  occurs,  the  fluid  contents 
of  the  intestine  above  the  occluded  part  appear  to  be  very 
copious.  To  some  degree  the  bowel  above  the  obstruction 
is  distended  by  the  actual  accumulation,  and  such  accumu- 
lation tends  to  favour  congestion  of  the  bowel  wall. 

Meteorism  is  not  due  to  a  mere  collection  of  gas  which 
cannot  escape.  The  circumstances  which  most  favour  it  are 
such  as  lead  to  gross  disturbance  in  the  circulation  of 
the  gut. 

clinically,  this  is  very  noticeable.  Meteorism  is  marked 
when  the  mesentery  or  mesocolon  is  largely  involved  in  stran- 
gulation.     Tliis  is  well  illustrated  by  examples  of  extensive 


16  GENEBAL    PATHOLOGY. 

volvulus.  No  distension  of  the  intestine  can  equal  that  ex- 
hibited by  a  volvulus  of  a  sio^ruoid  flexure  of  exceptional 
length  in  which  the  mesocolon  has  been  so  twisted  as  to  cut 
off  the  blood  supply  from  the  whole  coil.  Thrombosis  of  the 
mesenteric  vessels  tends  to  favour  intense  meteorism.  In- 
deed, one  of  the  most  extreme  examples  of  flatulent  distension 
of  the  abdomen  which  I  have  seen  occurred  in  a  patient 
who  had  no  intestinal  obstruction,  but  who  exhibited  post 
•niortem  extensive  thrombosis  of  the  mesenteric  veins. 

In  the  cases  of  intestinal  obstruction  the  meteorism  is 
obviously  favoured  by  the  loss  of  contractility  in  the  bowel, 
and  this  condition  is  very  marked  when  the  circulation  in 
the  loop  has  been  arrested.     (Compare  Groups  II.  and  III.) 

The  advent  of  peritonitis  increases  the  degree  of  paresis, 
and  is  followed  by  an  augmentation  of  the  meteorism. 

Mere  abrupt  occlusion  of  the  gut  without  disturbance 
of  its  circulation  leads  to  an  accumulation  of  the  bowel 
contents  above  the  strictured  part.  Gas  collects  at  this  point, 
and  is  unable  to  escape  downwards,  but  the  actual  distension 
of  the  bowel  produced  is,  in  these  acute  cases,  compara- 
tively slight,  and  can  hardly  be  said  to  reach  the  degree 
of  meteorism. 

The  General  Pathology  of  Obstruction  of  the 
Bowel. — The  condition  to  be  considered  under  this  heading 
is  illustrated  by  stricture  of  the  bowel  or  any  stenosis  of 
gradual  formation.  The  bowel  is  narrowed,  but  not  oc- 
cluded. The  intestinal  contents  can  pass,  but  pass  with 
difficulty.     There  is  obstruction,  but  not  occlusion. 

It  is  to  be  assumed  that  the  narrowing  has  formed 
slowly  and  gradually,  and  therefore  that  the  case  is  chronic. 

The  best  example  of  this  condition  is  afforded  by  a 
malignant  stricture  of  the  colon. 

The  bowel  below  the  obstruction  is  empty  and  con- 
tracted. It  contrasts  in  a  very  marked  manner  with  the 
intestine  above  the  seat  of  stenosis.  It  is  in  a  state  of  feeble 
tonic  contraction,  the  so-called  "  inanition  contraction,"  its 
colour  is  pale,  and  its  walls  are  unchanged.  It  is  in  the  con- 
dition, in  fact,  of  the  starvation  intestine.  Now  and  then 
it  may  show  some  distension  due  to  gas  produced  by  the 
decomposition  of  such  matters  as  have  passed  through  the 
strictures.  These  matters  in  neglected  cases  may  form  sub- 
stantial accumulations  in  the  bowel,  and  may  even  be  rx:fained 
long  enough  to  induce  catarrh.  The  rectum  below  an 
obstructed  colon  may  be  found  to  be  dilated,  and  in  the 
condition  known  as  the  "  ballooned  rectum."  This  curious 
state   is   apparently   the  result   of  some   nerve  disturbance. 


EFFECTS    OF    OBSTRUCTION.  ]7 

and  I  have  never  seen  any  condition  equivalent  to  it  in 
any  part  of  the  colon  below  a  stricture. 

The  distension  of  the  colon  with  gas,  which  is  occasion- 
ally met  with  below  the  stricture,  has  never  in  my  experience 
been  sufficiently  marked  to  lead  to  the  risk  of  the  coil  being 
mistaken  for  a  loop  above  the  stricture.  This  is  a  matter 
of  some  moment  because  cases  have  occurred  in  which  a 
colotomy  has  been  performed,  and  the  opening  found  to 
have  been  made  below  the  obstruction. 

The  bowel  above  the  obstruction  becomes  dilated,  and 
its  walls  hypertrophied.  These  changes  are  most  intense 
close  to  the  stricture,  and  gradually  diminish  as  the  site 
of  the  obstruction  is  departed  from.  They  are  more  marked 
when  the  colon  is  involved  than  when  the  stenosis  concerns 
the  small  intestine. 

In  lono-- standing  cases  the  changes  in  the  bowel  above  the 
stricture  are  considerable  and  far  spread.  Thus,  in  cases  of 
stricture  of  the  sigmoid  flexure,  not  only  has  the  whole  colon 
been  found  dilated  and  hypertrophied,  but  also  the  terminal 
portion  of  the  ileum.  The  bowel  may  be  greatlj^  contorted 
and  much  lengthened. 

The  distension,  especially  where  the  colon  is  involved, 
may  be  enormous.  Thus,  in  a  case  of  cancer  of  the  sigmoid 
flexure  causing  stricture,  reported  by  Dr.  Fagge,"^  the  splenic 
flexure  of  the  colon  was  found  to  be  as  large  as  a  distended 
stomach.  In  a  case  of  stricture  of  the  splenic  flexure  by  the 
same  author  the  csecum  was  found  to  be  as  large  as  the  calf  of 
the  leg.  In  another  instance,  where  the  stenosis  had  involved 
the  descending  colon,  the  large  intestine  above  the  obstruction 
had  a  diameter  of  from  eleven  to  twelve  inches.f  The 
enormous  distension  of  which  the  colon  is  capable  is  well 
illustrated  by  a  specimen  in  St.  Bartholomew's  Hospital 
Museum,!  showing  the  large  intestine  of  a  child  (who  died 
of  rectal  stricture)  that  has  a  diameter  of  more  than  one 
foot. 

The  hypertroph}^  is  a  true  hypertrophy  of  muscle,  and  not 
a  mere  hyperplasia.  It  is  due  to  abiding  efforts  on  the  part 
of  the  intestine  to  force  matters  through  the  narrow  strait 
in  the  bowel.  It  is  the  outcome  of  overwork.  The  hyper- 
trophy concerns  more  conspicuously  the  circular  fibres.  Ex- 
periments upon  animals  shoAv  that  this  hypertrophy  may 
commence  as  early  as  the  fifth  day  after  the  lumen  of  the 
bowel  has  been  narrowed,  and  that  it  may  be  quite  evident  by 
the  ninth  day.     When  the  intestine  has  attained  a  certain 

*  Guy's  Hosp.  Reports,  vol.  xiv.,  p.  272. 
t  Lancet,  vol.  ii.,  1876,  p.  505.  J  Xo.  1052. 

C 


18  GENERAL    PATHOLOGY. 

degree  of  h3q3ertropliy,  and  has  yet  failed  to  overcome  the 
obstruction,  there  iinally  appears  a  degeneration  and  an 
atrophy  of  the  hypertrophied  fibres.  The  bowel  wall  becomes 
enormously  increased  in  thickness.  The  intestine  feels  heavy, 
firm,  and  leathery.  In  the  colon  the  longitudinal  bands  stand 
out  with  remarkable  clearness.  The  vessels  of  the  intestine 
are  very  prominent,  and  the  gut  becomes  a  little  deeper  in 
colour. 

The  mucous  membrane  of  the  bowel  is  thickened  from 
chronic  catarrh,  and  is  very  commonly  ulcerated.  These 
inflammatory  changes  are  more  marked  in  the  colon  than  in 
the  small  intestine,  and  are  most  pronounced  just  above 
the  narrowed  part.  They  are  due  to  the  long-continued 
distension,  to  the  constant  pressure  of  retained  fyecal  matter, 
to  the  actual  mechanical  impact  of  solid  masses,  and  to  the 
chemical  and  bacteriological  effects  of  decomposition  set  up  in 
long-retained  intestinal  matters.  It  will  be  evident,  therefore, 
Avhy  such  manifestations  of  inflammation  are  more  marked  in 
the  colon. 

In  the  small  intestine  ulcers  are  found  above  the  stricture, 
and  perforation  of  these  ulcers  is  a  common  cause  of  death. 
The  ulceration  is,  as  a  rule,  situated  just  above  the  stenosed 
part,  and  if  perforation  occurs  it  will  occur  here.  There  are 
a  few  exceptional  cases.  Thus,  for  example,  in  a  case  of 
stricture  of  the  ileo-cascal  valve  a  perforation  was  found  to 
have  taken  place  in  the  middle  of  the  ileum,  and  on  the 
other  hand  several  feet  of  the  small  intestine  above  a  stricture 
may  be  the  seat  of  ulceration.  These  changes,  however,  in 
the  mucous  membrane  above  the  stricture  are  best  studied  in 
the  colon. 

This  segment  of  the  colon  commonly  presents  a  con- 
dition of  extensive  colitis.  The  degree  of  this  inflammation 
varies.  It  is  usually  of  a  chronic  type,  the  mucous  mem- 
brane is  pigmented,  and  may  appear  in  places  to  be  sloughy. 
Some  ulceration  is  usual.  The  ulcers  may  be  quite  super- 
flcial,  and  appear  as  mere  erosions.  As  a  rule,  however, 
they  extend  in  depth  and  size,  they  present  ragged  and 
irregular  edges,  and  in  time  lay  bare  the  muscular  coats. 
They  spread  and  fuse  together,  and  so  produce  immense 
tracts  of  severe  ulceration.  Ulceration  of  this  type  may 
involve  the  Avhole  colon.  In  some  reported  cases  of  stric- 
ture of  th.e  rectum  the  entire  colon  is  described  as  being 
"  worm-eaten  "  with  innumerable  ulcers.  Certain  of  the  less 
aggressive  ulcers  are  evidently  of  long  standing,  and  show 
marked  nigmentation. 

lu  the  majority  of  instances  the  ulceration  is  of  limited 


EFFECTS    OF    OBSTRUCTION,  19 

extent.  When  the  stricture  is  at  some  distance  from  the 
valve,  ulceration  may  be  noted  in  two  distinct  j^laces,  namely, 
just  above  the  obstruction  and  in  the  cnecum,  the  intervening 
mucous  membrane  being  healthy.  This  has  been  met  with 
several  times  in  stricture  of  the  sigmoid  flexure.  When 
perforation  occurs  in  colic  strictures  the  abnormal  aperture 
may  be  either  just  above  the  stricture  or  in  the  ciecum. 
The  relative  proportion  of  perforation  in  these  two  places 
is  as  seven  to  four. 

In  several  cases  where  ulcers  have  been  found  in  the 
csecum  similar  lesions  have  been  at  the  same  time  met  with 
in  the  ileum.  In  one  instance  of  simple  stricture  of  the 
splenic  flexure  there  was  an  annular  ulcer  in  the  colon  just 
above  ithe  obstruction,  and  six  large  ulcers  in  the  lower 
end  of  the  ileum.  No  other  part  of  the  bowel,  not  even 
the  caecum,  was  involved.  A  fatal  perforation  had  occurred 
in  the  loAver  ileum.  "^ 

The  perforating  ulcer  above  the  stricture  need  not  open 
into  the  peritoneal  cavity.  In  a  few  rare  cases  where 
adhesions  have  formed  the  perforation  has  been  so  j)]aced 
as  to  give  temporary  relief  at  least  to  the  obstruction.  Thus 
in  one  case  of  stricture  of  the  valve,  the  ileum  opened  into 
the  commencement  of  the  colon,  forming  a  fistula  bimucosa 
through  which  the  faeces  could  pa.ss.t  Other  cases  of  relief 
by  the  formation  of  such  a  fistula  have  been  reported ;  also 
an  instance  where  the  colon  above  a  stricture  in  a  distorted 
sigmoid  flexure  was  found  to  have  opened  into  the  bladder 
and  rectum.  J 

If  the  perforation  take  place  very  slowly,  a  sacculated 
fsecal  abscess  may  be  produced,  or  there  may  follow  a 
severe  and  ill-conditioned  cellulitis  of  the  retro-peri- 
toneal tissue.  I  have  seen  a  case  in  which  a  fsecal  abscess 
in  the  left  iliac  fossa  was  the  first  sign  of  cancer  of  the 
sigmoid  flexure. 

Sometimes  the  changes  in  the  bowel  above  the  obstruc- 
tion pass  the  limits  of  ulceration,  and  the  part  becomes 
gangrenous.  Gangrene  developed  in  these  circuujstances 
is  usually  found  in  obstructions  of  the  colon  onl}^,  and  it 
is  only  in  this  part  of  the  intestine  that  gangrene  of  an 
extensive  character  is  met  with.  Dr.  Moxon  has  recorded 
a  good  example  of  this  condition.  The  stricture  was  in  the 
sigmoid  flexure,  the  patient  an  adult.  The  anterior  wall 
of  the  ascending  colon  was  wanting  (having  sloughed)  over 

*  Bull,   de  la  Soc.  Anat.,   1870,  p.  27. 
t  Path.  Soc.  Trans.,  vol.  xxi.  p.    171. 
X  Ibid.,  vol.  i.,  p.  261. 


•20 


GENERAL    PATHOLOGY. 


an  area  measuring  five  inches  by  one  inch  and  a  half. 
Ef.cape  of  the  contents  had,  however,  been  prevented  by 
the  great  omentum,  "which  had  become  adherent  over  the 
gap,  and  had  closed  it.  Dr.  Goodhart  has  placed  upon 
record  a  still  more  pronounced  instance.  In  this  case  the 
sUicture   was  also   at   the   sigmoid  flexure,  and  the  patient 


i'lO.  2. — Great  saccii'-ation  of  the  Transverse  Colon  due  to  a  Stricture  at  the 
Splenic  Flexure. 

Tiie  wall  of  the  gut  is  miicli  liypertrophied.      {Royal  CM.  of  Surg.  Mus.,  No.  2453a.) 


an  adult.  A  great  part  of  the  transverse  colon  and  nearly 
the  whole  of  the  descending  colon .  were  gangrenous,  the 
mucous  membrane  here  being  especially  involved.  Cases 
of  less  extensive  gangrene  leading  to  rupture  of  the  gut 
are  fairly  common.  The  gangrene  in  these  instances  is  due 
partly  to  obliteration  of  the  vessels  in  the  intestinal  wall 
by  pressure  and  distension,  and  partly  to  the  irritating  action 
of  retained  feeces. 

Often  above  the  stricture  is  a  distinct  pouch  diiC  to 
distension  acting  probably  upon  walls  already  diseased.  The 
walls  of  the  pouch  are  thin,  the  mucous  lining  is  frequently 


EFFECTS    OF    OBSTRUCTION.  2l 

ulcerated,  and  that  ulceration  often  leads  to  fatal  per- 
foration. These  pouches  are  more  connnonly  met  with 
in  connection  with  simple  than  with  malignant  strictures, 
and  are  more  common  in  the  small  than  in  the 
large  intestine.  An  extreme  degree,  however,  of  sac- 
culation of  the  colon  above  a  stricture  is  shown  in 
Fig.  2.     {See  also  page  57.) 

It  is  remarkable  in  how  many  cases  cherry  and  plum 
stones  have  been  found  in  these  pouches  or  in  the  distended 
intestine  above  a  simple  stricture.  The  most  curious  case 
of  this  kind  is  reported  by  Dr.  Wickham  Legge.  The  patient, 
a  female  aged  twenty-six,  for  several  years  before  her  death 
evacuated,  on  various  occasions,  cherry  stones  with  her  stools. 
She  also  vomited  a  few.  During  life  a  mass  of  cherry  stones 
could  be  felt  through  the  parietes,  giving  to  the  hand  a 
peculiar  sensation  as  they  were  rubbed  together.  At  the 
autopsy  a  stricture  of  the  ileo-ca3cal  valve  was  found,  and 
above  it  in  the  small  intestine  an  imperial  pint  of  fruit 
stones.^  In  another  case  of  stricture  of  the  ileo-csecal  valve 
nearly  a  litre  of  cherry  stones  was  found  above  the  obstruc- 
tion, t  In  a  case  reported  by  Dr.  Peacock  there  were  found 
in  a  pouch  above  a  stricture  of  the  small  intestine  thirty- 
three  plum  stones,  sixteen  cherry  stones,  and  six  orange 
pips.  J  In  another  very  similar  instance  there  were  only 
three  plum  stones  in  the  pouch.  §  Dr.  Moore  has  recorded 
a  case  of  accumulation  of  a  large  number  of  cherry  stones 
above  a  simple  stricture  of  the  descending  colon.  ||  In  most 
of  the  instances  these  foreign  bodies  had  led  to  perforation 
of  the  bowel 

In  one  case  in  which  I  was  excising  the  sigmoid  Hexure 
for  an  epitheliomatous  growth  which  had  caused  a  tight 
stricture,  I  found  in  the  greatly  dilated  bowel  above  the 
stenosis  a  number  of  cherry  stones  which  had  been  swalloAved 
nine  months  before  the  operation. 

In  one  curious  case  of  stricture  of  the  lesser  bowel  a 
conical  pouch  or  funnel  was  found  to  hang  down  into  the 
lower  part  of  the  intestine.  It  had  an  aperture  at  its  apex, 
and  through  it  all  the  faeces  had  passed.  The  funnel-like 
process  was  large  and  conspicuous,  and  is  well  depicted  in 
Fig.    3.^       It    was    probably    produced     by    the    excessive 

*  Path.  Soc.  Trans.,  vol.  xxi.,  p.  171 . 
■  t  V Union  2Ied.,'\^bQ,  1^0   bl. 
X  Path.  Soc.  Trans.,  vul.  x.,  p.  154. 
§  Tbid.,  vol.  iv.,  p.  1.52. 
II  Lancet,  vol.  ii.,  1876,  p.  505. 
U  St.  Thomas's  Ho.sp.  Museum,  No.  Q.  129. 


GEXEBAL   PATHOLOGY. 


enlargement  of  a  simple  poucli  formed  above  the  strictm^e. 
The  fimdiis  of  the  pouch  would  be  pressed  against  the  wall 


Fig.  3. — Stricture  of  the  small  Intestine  with  Pouch. 
a  aiKl  a'  point  to  fraiia  holding  in  position  a  lemarlialjle  ponch  of  niiicous  membrane. 


ot  the  gut  below  the  stricture,  until  at  last  perforation  into 
that  part  of  the  intestine  would  occur,  and  the  formation 
of  the  lunnel-like  process  would  be  complete.  It  may  be 
noted  that  in  the  specimen  the  mucous  lining  of  the  process 


EFFECTS    OF    OBSTBUGTIOX.  23 

can   be   seen    to  be  continuous    with    that   of  the   intestine 
above. 

It  is  common  to  find  about  simple  strictures  of  the 
lesser  bowel  certain  frpena  and  bars  of  cicatricial  tissue 
which  are  appaiently  the  products  of  an  irregular  ulcera- 
tion, and  possibly  of  the  adhesions  of  adjacent  inflamed 
surfaces. 


24 


CHAPTER   II. 

THE    ]\IORBID    ANATOMY    OF    PARTICULAR    FORMS    OF 
INTESTINAL    OBSTRUCTION. 

Strangulation  by  Bands  or  through  Apertures. — 
Under  this  variety  of  intestinal  obstruction  may  be 
included : — 

1.  Strangulation  by  isolated  peritoneal  adhesion. 

2.  Strangulation  by  cords  formed  from  the  omentum. 

3.  Strangulation  by  Meckel's  diverticulum. 

4.  Sti'angulation  by  normal  structures  abnormally  attached   (sucli 

as  by  an  adherent  vermiform  appendix  or  Fallopian  tube, 
or  by  a  fixed  mesentery),  including  strangulation  by  the 
pedicle  of  an  ovarian  tumour  and  the  like. 

5.  Strangulation  through  slits  and  apertures  in  the  mesentery  or 

omentum,  or  in  certain  peritoneal  ligaments,  or  through 
membranous  adhesions. 

These  various  forms  may  be  conveniently  considered 
together,  for  although  in  each  case  the  anatomical  cause 
of  the  obstruction  is  different,  yet  the  effects  upon  the  gut 
are  in  all  instances  practically  identical.  In  each  the  segment 
of  bowel  involved  is,  almost  without  exception,  the  small 
intestine.  In  each  the  mechanism  of  the  obstruction  is 
practically  the  same.  In  each  the  symptoms  that  arise  are, 
Avith  some  minute  exceptions,  so  nearly  identical  that  they 
may  be  studied  as  a  whole.  In  each  the  course  and  issue 
of  the  malady  are  such  that  these  various  forms  may  be  said 
to  share  a  common  23roo-nosis.  Between  them  all,  moreover, 
there  is  a  close  bond  of  union  in  the  fact  that  they  are 
adapted  for  the  same  form  of  treatment,  and  may  be  relieved 
by  tlie  same  operative  procedures. 

Considered  as  a  whole,  this  form  may  be  taken  as  the 
type  of  acute  intestinal  obstruction.  It  is  the  strangidated 
hernia  of  the  interior  of  the  abdomen.  It  obstructs  the  gut 
as  a  hernia  obstructs.    The  symptoms  that  attend  this  variety 


STRANGULATION   BY    BANDS.  25 

of  intestinal  obstruction  are,  in  all  main  points,  the  syniptoins 
of  strangulated  hernia,  and  the  prognosis  of  the  two  aft'ections 
depends  rather  upon  the  situation  of  the  constricting  agent 
than  upon  any  other  factor.  It  is  for  many  reasons  a  matter 
of  moment  to  note  that  strangulated  hernia  and  the  different 
forms  of  internal  obstruction  above  described  are  but  varieties 
of  a  single  malad}^  that  they  differ  from  one  another  solely 
on  anatomical  grounds,  that  in  their  pathology  and  in  the 
broader  lines  of  their  chnical  history  they  are  the  same, 
and  that,  excluding  the  taxis,  they  are  amenable  to  the 
same  general  form  of  surgical  treatment. 

It  will  be  convenient  to  consider  the  pathological 
anatomy  of  these  five  varieties  of  obstruction  separately, 
and  their  symptoms  and  the  elements  of  their  prognosis 
collectively. 

"  Internal  hernia; "  are  considered  in  a  separate 
section  (page  102).  Certain  of  these  hernia?  conform 
to  the  type  of  intestinal  obstruction  now  under  dis- 
cussion ;  others  by  no  means  so  conform.  The  conditions 
described  as  internal  hernise  present  such  varied  ana- 
tomical features  and  such  diverse  clinical  developments 
that  they  are  conveniently  dealt  with  under  one  special 
heading. 

1.  Strangulation  by  Isolated  Peritoneal  Adhesions.  The 
CAUSES  OF  THE  BAND. — Theso  isolated  adhesions  (known 
commonly  as  "  bands,"  "  solitary  bands,"  or  "  peritoneal  false 
ligaments ")  are  the  results  or  residues  of  some  form  of 
peritonitis.  Owing  to  the  high  mortality  of  acute  diffused 
peritonitis  on  the  one  hand,  and  the  very  general  and  ex- 
tensive adhesions  commonly  produced  by  chronic  diffused 
^peritonitis  on  the  other,  it  follows  that  these  isolated  bands 
are  usually  due  to  moderate  and  well  localised  forms  of  peri- 
toneal inflammation. 

Among  the  phases  of  local  peritonitis  the  following  may  be 
mentioned  as  the  most  common  antecedents  of  the  "band" 
or  "  false  ligament  "  : — perityphlitis,  pelvic  peritonitis,  peri- 
tonitis following  upon  injury,  upon  abdominal  operations, 
upon  strangulated  hernia,  upon  ulceration  of  the  bowel  and 
upon  mesenteric  gland  disease.  Tuberculous  peritonitis  which 
has  ended  in  real  or  apparent  recovery  may  also  be  a  factor 
in  the  etiology. 

Among  six  cases  of  strangulation  by  bands  alluded  to  by 
Dr.  Coats"^"  no  less  than  four  appear  to  have  owed  their  origin 
to  healed  tuberculous  trouble. 

This  form  of  strangulation  may  occur   even   during    the 

»  Trans.  Path,  and  Clin.  Soc,  Glasgow,  1893,  vol.  iv. 


26  MORBID    ANATOMY. 

progress  of  the  disease.  Larguier  des  Bancels^  reports  the  case 
of  a  boy,  aged  eight,  who  daring  the  progress  of  tuberculous 
peritonitis  developed  symptoms  of  acute  obstruction,  of  which 
he  soon  died.  The  autopsy  revealed  a  coil  of  the  lower  ileum 
strangulated  by  a  band,  one  of  the  many  resulting  from  the 
disease  of  the  serous  membrane. 

So  little  is  known  of  the  reputed  "  intra- uterine  perito- 
nitis "  that  -the  assertion  that  some  bands  are  due  to  this 
condition  may  be  considered  as  not  proved.  Most  of  the 
"  congenital  bands "  depend  upon  developmental  defects  in 
the  vitelline  duct. 

From  my  own  experience  I  should  say  that  one  of  the 
most  common  causes  of  the  peritoneal  false  ligament  is 
perityphlitis.  It  is  needless  to  state  that  of  all  forms  of 
limited  peritonitis  this  form  is  the  most  frequently  met 
with. 

I  have  knowledge  of  several  instances  in  which  "  pelvic 
inflammation,"  "  metritis,"  or  "  pelvic  cellulitis  "  appears  with- 
out doubt  to  have  provided  the  band.  In  one  fatal  case  of 
acute  strangulation  under  my  care  the  obstructing  false 
ligament  was  produced  by  a  localised  peritonitis  which  had 
followed  an  excision  of  the  rectum.  The  instances  in  which 
intestinal  obstruction  of  the  present  type  has  followed  upon 
an  abdominal  operation  are  quite  numerous. 

Lucas- Championnieref  makes  mention  of  five  instances 
in  which  symptoms  of  intestinal  obstruction  appeared  in  a 
few  days  after  operations  which  concerned  the  abdominal 
viscera. 

Dr.  G.  RoheJ  in  a  very  exhaustive  paper  upon  this  sub- 
ject deals  with  seventy-five  examples  of  death  from  intestinal 
obstruction  following  upon  abdominal  operations. 

In  the  majority  of  the  instances  the  obstruction  was  duo 
to  adhesions  and  peritoneal  bands.  It  is  well,  however,  to 
mention  here  that  certain  reported  cases  of  death  from  in- 
testinal obstruction  after  laparotomy  certainly  appear  to  be 
rather  cases  of  peritonitis.  This  is  especially  the  case  in  the 
somewhat  numerous  instances  in  which  death  is  ascribed  to 
"septic  intestinal  paralysis." 

I  have  described  elsewhere§  the  various  forms  of  intestinal 
obstruction  Avhich  may  follow  after  hernia,  and  although 
strangulation  by  an  adherent  band  or  omental  cord  has  been 

*  Sur  le  Diagnostic  et  le  Traitement  des  Elranglements  Internes.  These  do 
Piiris,   1870. 

t  Revue  de  Chinirgie,  1892,  p.  264. 

X  American  Journ.  of  Obstetrics,  Oct.,  1894. 

§  Lancet,  June  7,  1884. 


STRANGULATION  BY  BANDS.  27 

met  with  after  hernia  it  is  not  a  conniion  phase  of  the  trouble. 
(See  page  41.) 

The  patch  of  peritonitis  which  may  form  over  the  site  of 
any  deep  intestinal  ulcer  may  attract  a  fringe  of  omentum 
and  form  an  omental  cord,  or  it  may  lead  to  an  adhesion 
between  another  coil  of  bowel  which  may  in  time  become  a 
strano'ulating  aa^ent. 

With  regard  to  mesenteric  gland  disease,  the  little  local 
peritonitis  excited  in  the  serous  membrane  covering  the 
glands  may  lead  to  the  adhesion  of  a  free  diverticulum, 
or  of  the  free  end  of  the  omentum,  or  may  encourage  the 
development  of  bands  which  may  in  turn  prove  a  cause 
of  intestinal  strangulation.'^ 

This  is  not,  however,  the  only  form  of  obstruction  which 
may  be  indirectly  due  to  this  variety  of  gland  disease,  and 
to  avoid  repetition  they  may  be  alluded  to  in  passing. 

The  local  peritonitis  may  lead  to  adhesions  being  formed 
between  two  remote  parts  of  the  intestinal  tube.  Thus,  in 
a  case  recorded  by  Dr.  Hilton  Fagge  the  sigmoid  flexure 
%vas  found  attached  to  the  ileum,  and  in  the  angle  between 
these  two  adherent  portions  of  gut  was  a  caseous  gland. f 

The  ileum  about  the  seat  of  a  diseased  gland  in  the 
mesentery  may  become  sharply  bent  upon  itself;  and 
between  the  two  limbs  of  the  loop  so  formed,  and  fusing 
them  together,  as  it  were,  will  often  be  found  an  old  and 
degenerate  gland. 

Or  the  bending  may  be  very  limited  and  well  localised,' 
so  that  a  fold  of  the  bowel  is  turned  in  and  forms  a  species 
of  diaphragm.  This  condition  is  shown  in  the  remarkable 
case  depicted  in  Fig.  92. 

In  several  instances  the  shrinking  of  the  mesentery  after 
extensive  gland  disease  has  been  so  considerable,  and  has 
produced  so  much  distortion,  as  to  lead  to  a  fatal  obstruc- 
tion of  that  part  of  the  bowel  connected  with  the  diseased 
area.  X 

The  Mode  of  Formation  of  the  Band. — The  actual 
production  of  the  band-like  adhesion  after  peritonitis  is 
easily  demonstrated. 

It  is  well  known  that  in  this  affection,  and  especially 
in  the  so-called  adhesive  form,  a  librinous  exudation  appears 

*  See  specimens,  Guy's  Hosp.  Museum,  No.  1819  (36)  ;  and  St.  Bart.'.s  Ho=p. 
Museum,  No.  2165  ;  also  cases  by  M.  Bricheteau  (Bull,  de  la  Soc.  Anat.,  1861, 
p.  118),  and  by  Rlr.  B.  Hill  {Lancet,  vol.  i.,  1876),  p.  773. 

f  Path.  Soc.  Trans.,  vol.  xxvii.,  p.  1.57. 

X  See  Path.  Soc.  Trans.,  vol.  xxi,,  p.  187;  and  cases  by  Dr.  Fagge, 
Guj's  Hosp.  Keports,  vol.  xiv.,  p.  272. 


28  MORBID    ANATOMY. 

upon  the  surface  of  the  inflamed  membrane.  Any  two  sur- 
faces may,  through  the  medium  of  the  exudation,  become 
adherent  if  they  be  brought  into  contact  with  one  another. 

The  adhesion  may  be  over  a  very  extensive  surface,  or 
may  involve  only  a  lew  isolated  points.  As  the  inflamma- 
tion subsides  there  is  no  doubt  that  the  greater  part  of 
the  exudation  is  in  time  absorbed.  I  have  many  times 
found  the  extensive  soft  adhesions  exposed  in  operating  for 
perityjjhlitic  abscess  to  have  entirely  vanished  when  the 
affected  region  has  been  laid  open  at  a  second  operation. 

It  is,  so  far  as  I  know,  impossible  to  state  under  what 
conditions  adhesions  will  persist  on  the  one  hand  or  vanish 
on  the  other.  Extensive  and  tough  adhesions  may  folloAV 
upon  a  peritonitis  of  moderate  degree,  while  little  or  no  trace 
may  be  left  of  a  peritonitis  of  a  quite  acute  character. 

That  there  is,  however,  considerable  absorption  of  the 
fibrinous  exudation  in  every  case  there  is  little  doubt.  What 
remains  becomes  organised  into  fibrous  tissue,  and  so  are 
produced  " adhesions,"  "bands,"  "peritoneal  false  ligaments," 
and  the  like. 

Some  of  these  adhesions  may  be  extremely  loose  and 
delicate,  while  others  are  composed  of  a  more  substantial 
material.  It  would  appear  that  many  of  the  more  flimsy 
of  these  uniting  structures  in  time  disappear,  even  after 
they  have  become  organised  into  definite  connective  tissue. 

One  circumstance  which  has  distinct  influence  in  this 
direction  is  certainly  the  movement  of  the  adhering  parts. 
During  the  progress  of  peritonitis  the  intestines  are  re- 
latively still  and  more  or  less  distended.  As  a  result 
of  this  distension  coils  of  bowel  may  be  brought  together 
which  were  hitherto  far  apart,  or  a  certain  loop  may  be 
placed  in  association  with  a  comparatively  distant  point  on 
the  parietes.  When  the  inflammation  has  subsided,  the  parts 
return,  as  far  as  possible,  to  the  status  quo  ante;  peristaltic 
movements  spread  through  the  intestine,  coils  which  were 
close  together  tend,  as  a  result  of  those  movements,  to 
become  separated,  and  adhesions  that  attach  the  intestine 
to  points  upon  the  parietes  are  persistently  dragged  upon. 
It  follows  from  this  almost  constant  tension  that  the  still 
soft  adhesion  yields,  becomes  elongated  and  thinned,  ulti- 
mately gives  way  and  is  absorbed. 

Movement  also  has  great  influence  upon  the  future 
physical  characters  of  the  adhesion.  Most  of  the  adhesions 
assume  primarily  a  membranous  character,  and  this  they  may 
retain  throughout  their  existence  (Fig.  85).  It  is  not  uncom- 
mon to  find  some  coils  of  intestine  matted  together  by  an 


STRANGULATION    BY   BANDS.  29 

extensive  series  of  false  membranes,  Avhich  appear  sometimes 
as  wide  expansions,  at  other  times  as  thin  but  broad  ribbon- 
like  bands,  of  all  dimensions  and  of  various  lengths  (Figs.  4 
and  30).  If  two  distant  coils  of  small  intestine  have  been 
brought  together  during  peritonitis,  and  have  become 
attached  to  one  another  by  means  of  the  exudation,  or 
if  a  like  attachment  has  taken  place  between  the  intestine 
and  the  parietes,  then,  as  movement  is  restored  in  the 
bowel,  the  adhesions,  which  may  be  quite  membranous,  are 
dragged  upon,  and  as  a  result  become  elongated.  As  they 
increase  in  length  so  must  they  become  attenuated  in  width 
and  thickness.  The  constant  tension,  moreover,  probably 
interferes  with  their  already  feeble  nutrition,  and  induces 
a  further  wasting.  The  wide  membranous  adhesion  may 
thus  become  narrowed  and  ribbon-like. 

It  may,  however,  undergo  a  still  further  change.  The 
adhesion,  subjected  to  the  rolling  movements  of  the  intestines 
over  one  another,  and  to  frequent  torsion,  now  in  one  direction 
and  now  in  the  other,  tends  to  become  rounded  and  cord-like, 
and  the  more  it  is  stretched  the  more  completely  is  this 
transformation  favoured.  Thus  are  formed  "  peritoneal  false 
ligaments  "  and  the  bands  and  cords  now  under  discussion. 

The  moulding  of  a  mass  of  adhesion-tissue  into  a  cord 
by  movements  within  the  abdomen  is  illustrated  by  the 
changes  effected  by  those  movements  in  the  omentum  when 
it  becomes  adherent.  This  structure  may  become  attached 
by  its  free  extremity,  and  in  the  course  of  time,  if  the 
abdomen  be  opened,  it  will  be  found  to  be  changed  into  a 
corcl-like  mass.  The  intestines  in  their  movements  have 
rolled  over  and  under  and  about  the  adherent  membrane, 
and  at  last  they  have  moulded  it  almost  as  a  piece  of  clay 
may  be  moulded  when  rubbed  between  the  palms.  This 
change  is  best  brought  about  when  the  situation  of  the 
adhesion  is  such  as  to  keep  the  membrane  on  the  stretch. 

A  like  metamorphosis  may  be  effected  in  any  smaller  part 
of  the  great  omentum  which  may  have  become  adherent  to 
a  distant  point. 

By  a  combination  of  these  various  circumstances,  by 
a  stretching  of  the  adhesion  on  the  one  hand,  by  its 
consequent  attenuation  on  the  other,  and  its  subjection  to 
the  moulding  influences  of  moving  intestines  for  the  third 
part,  it  happens  that  cords  and  bands  of  great  length  are 
often  produced  as  a  result  of  peritonitis.  Many  instances 
may  be  given,  but  one  of  the  most  striking  is  afforded  by 
a  case  reported  by  Mr.  Obre.^     In  this  example  a  cord-like 

*Path.  Soc.  Trans,,, vol.  iii.,  p.  95. 


30 


MORBID    ANATOMY. 


band  was  found  to  pass  from  a  coil  of  small  intestine  situated 
near  the  xiphoid  cartilage  to  the  parietal  peritoneum  about  the 
inguinal  canal.  The  false  ligament  measured  seventeen  and 
a  half  mches.  The  patient  had  had  a  strangulated  inguinal 
hernia,  and  there  was  clear  evidence  to  show  that  the 
herniated  bowel  had  been  that  to  which  the  cord  was 
attached. 

It  must  bo  remembered  that  not  only  may  these  bands 
form  arcades  beneath  which  coils  of  intestine  may  become 
strangulated,  but  the  longer  of  them  may  become  separated 
at  one  of  their  points  of  attachment,  and  so  form  floating 
cords  which  may  lead  to  strangulation  of  a  loop  by 
"  knotting.'' 

The  Form  axd  Disposition  of  the  Baxd. — The  appear 
ance  of  these  false  ligaments  and  bands,  in  cases  in  which 
they  have  produced  obstruction,  varies  greatly. 

Most  commonly  the  "  band "  takes  the  form  of  a  firm 
fibrous  cord  about  the  size  of  a  No.  4  or  No.  6  catheter. 
It  may  be  still  more  slender,  and  appear  as  a  tough,  rigid 
thread.     On  the  other   hand,   it   may   be   of  comparatively 


Fig.  4. — StraDgulation  by  a   broad  Peritoneal  Band  passing  between  two 
adjacent  Coils  of  Ileum. 


large  size  ;  thus  M.  Terrier  has  reported  a  case  of  internal 
strangulation,  for  which  he  performed  laparotomy,  where 
the  constricting  band  had  nearly  the  dimensions  of  the 
little  finger.^  The  cord-like  "  band  "  is  usually  described 
as  being  dense  and  fibrous,  and  in  one  or  two  instances  as 
being    of    almost    cartilaginous    hardness.      Less    frequently 

*  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Faris,  vol.  iv.,  1S79,  p.  56i 


STRANGULATION   BY   BANDS.  31 

the  constricting  agent  has  the  appearance  of  an  actual 
band,  and  in  such  cases  is  found  as  a  tough  ribbon-hke 
membrane,  with  a  width  of  half  an  inch  or  even  more.  A 
band  of  this  character  is  shown  in  Fig.  4.^ 

The  false  ligament  is  usually  single,  and  hence  the  name 
bestowed  upon  it  by  Mr.  Gay  of  "  the  solitary  band."  It 
must  not  be  assumed,  however,  that  such  a  band  commonly 
exists  as  the  solitary  adhesion  in  any  given  case.  It  most 
probably  will  be  the  only  isolated  adhesion,  and  the  only 
one  so  modified  as  to  be  capable  of  strangulating  the  bowel. 
But  in  cases  where  this  isolated  adhesion  is  met  with  other 
adhesions  will  often  be  found.  This  is  especially  the  case 
when  the  band  is  due  to  tuberculous  or  pelvic  peritonitis. 
The  same  applies,  although  in  a  less  degree,  to  the  local 
peritonitis  set  up  by  inflammation  about  the  caecum.  Here, 
in  addition  to  any  adhesion  which  may  have  become  isolated, 
elongated,  and  cord-like,  there  will  very  probabl}^  be  some 
matting  together  of  parts  in  the  immediate  vicinity  of  the 
appendix.  Many  cases,  however,  are  reported  where  the 
only  relics  of  a  perityphlitis  have  assumed  the  form  of 
one  solitary  band.  A  single  false  ligament,  the  repre- 
sentative of  a  single  adhesion,  may  be  produced  by  the 
very  localised  peritonitis  which  is  sometimes  associated 
with  caseous  degeneration  of  a  mesenteric  gland.  I  have 
met  with  several  cases,  and  not  a  few  specimens,  which 
illustrate   this   circumstance.! 

A  single  adhesion  may  readily  follow  upon  the  little 
speck  of  peritonitis  attending  an  intestinal  ulcer  (Fig.  32). 
As  the  ulcer  deepens  it  excites  an  inflannnation  over  a  very 
limited  area  of  the  serous  surface.  This  inflamed  spot  ad- 
heres to  some  other  point  on  the  peritoneum  ;  a  single 
adhesion  forms,  which,  becoming  elongated  by  the  method 
already  described,  forms  an  example  of  the  solitary  band. 

A  great  many  of  the  cases  of  "  solitary  band  "  described 
are,  however,  evidently  instances  of  Meckel's  diverticulum 
or  a  diverticular  ligament.  {See  page  46.)  I  am,  indeed, 
under  the  impression  that  the  majority  are  of  this  character. 

In  some  few  cases  there  have  been  two  or  more  false, 
ligaments  found  in  the  abdominal  cavity.  Sometimes  these 
would  appear  to  have  been  produced  by  the  thrusting  of 
a  coil  of  intestine  through  a  broad  peritoneal  adhesion,  so 
as  to  divide  it  into  two  segments.  In  other  instances  the 
bands  are  independent  of  one  another.      Mr.  Berkeley  Hill 

*  London  Hosp.  Museum,  No.  Ad.  78. 

t  Case  of  Glenard's  Disease,  treated  by  operation  by  tbe  author  (Brit.  3Ied. 
Journ.,  Jan.  4,  1896). 


31 


MORBID    ANATOMY. 


reports  a  case  of  acute  intestinal  obstruction  where  two 
bands  existed,  both,  of  which  constricted  knuckles  of  small 
intestine.  One  constriction  was,  however,  comparatively 
slight,  the  other  was  severe.  Laparotomy  was  performed, 
and  unfortunately  the  band  found  and  divided  was  that 
associated  with  the  minor  obstruction.  The  more  serious 
strangulation   was    overlooked,    and    the    child   died.      The 


Fio.  5.— strangulation  of  the  Ileum  by  a  Y-staped  Band  attached  to  the 
Fundus  of   the  Uteru?. 

The  uterus  is  .showu  at  the  lower  part  of  the  figure. 

adhesions  in  this  case  appear  to  have  been  due  to  mesenteric 
gland  disease."^ 

Mr.  Lupton  f  records  a  case  in  which  the  bowel  was 
constricted '  by  no  less  than  four  bands  in  four  separate 
places.  Symptoms  of  obstruction  had  lasted  over  seven 
.days.  The  operation  revealed  only  one  of  the  bands.  The 
patient  survived  the  operation  twenty- four  hours. 

The  false  ligament,  although  single,  may  have  a  com- 
plicated  arrangement,   and   lead   to   extraordinary  forms   of 

*  Lancet,  vol.  i.,  1876,  p.  773. 
t  Laneit,  May  1,  1897,  p.  1204. 


STRANGULATION    BY   BANDS. 


33 


constriction  of  the  bowel.  Thus  in  the  specimen  shown 
in  Fig.  5*  there  was  one  isolated  adhesion.  It  was,  how- 
ever, broad  and  Y-shaped;  one  end  of  the  Y  was  attached 
to   the   uterus,   while   the   two   other  ends   were   connected 


jj^o,  6. Strangulation  of  the  Ileum  by  complicated  Bands  passing  between  the 

Uterus  and  Ovary. 


with  points  on  the  small  intestine  about  one  inch  and 
a  half  apart.  There  were  many  adhesions  about  the  pelvic 
viscera.  In  Fig.  6t  it  will  be  seen  that  an  adhesion 
connecting  the  uterus,  ovary  and  mesentery  leads  to  a 
complicated  form  of  strangulation  and  to  a  double  con- 
striction of  the  bowel. 

*  St.  Bart.'s  Hosp.  Museum,  No.  2164:. 
t  Guy's  Hosp.  Museum,  No.  2507  (50). 

D 


34  MORBID    ANATOiUY. 

In  many  cases  ot  strangulation  by  a  false  ligament  the 
circumstances  of  the  obstruction  are  complicated  by  simple 
adhesions  of  the  same  age,  and  due  to  the  same  cause  as 
the  so-called  ligament.  These  adhesions  may  have  matted 
together  into  a  knuckle  the  very  segment  of  the  bowel  which 
has   become   strangulated,  or  may  have   so   attached  them- 


Fio.   7.— StraTigulalion  of  small  Intestine  by  a  solitary  Band   attached  at  either 
end  to  the  Mesentery. 

selves  to  the  involved  intestine  as  to  encourage  a  volvulus 
of  it  v/hen  beneath  the  constricting  band. 

The  attachments  of  these  peritoneal  false  ligaments 
exhibit  the  greatest  possible  variety.  To  be  capable" of  pro- 
ducing a  strangulation  of  the  intestine  the  band  must  have 
at  least  two  points  of  attachment,  and  there  is  scarcely  any 
conceivable  combination  of  connected  points  which  is  not 
illustrated  in  the  history  of  these  adhesions. 

Most  commonly  the  strangulating  band  is  connected  by 
one  end  with  the  mesentery.  In  one  very  frequenfr  variety 
the  band  is  attached  by  both  its  extremities  to  the  mesentery. 


STRANGULATION  BY   BANDS.  35 

the  points  of  attachment  being  at  a  variable  distance  apart. 
This  disposition  of  the  band  is  illustrated  by  Fig.  7,"^  and 
it  would  appear  to  be  frequently  due  to  a  limited  peritonitis 
incident  upon  mesenteric  gland  disease,  f 

A  certain  number  of  "  bands  "  so  attached  are,  however, 
without  doubt  relics  of  incomplete  development  connected 
with  the  vitelline  duct.  In  that  large  series  of  cases  where 
the  isolated  adhesion  is  due  to  pelvic  peritonitis,  it  may 
be  found  to  be  attached  by  one  end  to  some  pelvic  viscus, 
and  by  the  other  to  a  neighbouring  part.  Thus  bands  are 
iound  passing  from  the  uterus,  or  ovary,  or  bladder,  to  the 
parietal  peritoneum  of  the  pelvis  or  abdomen ;  or,  starting 
from  the  same  source,  they  may  attach  themselves  to  the 
coecum  or  sigmoid  flexure,  or  with  much  greater  frequency 
to  some  part  of  the  lower  ileum  or  its  mesentery.  In 
several  instances  the  constricting  band  has  merely  passed 
from  one  point  on  the  pelvic  wall  to  another. 

When  the  band  has  been  caused  by  some  local  peri- 
tonitis in  connection  with  hernia,  one  of  its  extremities 
may  be  found  attached  in  the  vicinity  of  the  femoral  or 
inguinal  rings,  while  the  other  end  may  be  fixed  to  the 
intestine,  the  mesentery,  or  the  posterior  parietal  peritoneum. 
When  the  band  has  followed  after  perityphlitis,  both  ends 
ot  it  may  be  found  connected  with  the  cajcum  or  appendix-, 
as  is  apparently  the  case  in  a  specimen  in  the  Royal  College 
of  Surgeons  Museum  ;:|:  or  it  may  pass  between  the  caecum 
and  the  peritoneum  lining  the  iliac  fossa,  or  attach  itself 
to  the  ileum  or  to  its  mesentery,  or  become  connected  with 
the  lining  of  the  anterior  abdominal  wall.  In  some  cases, 
and  I  think  this  especially  occurs  after  very  localised  peri- 
tonitis due  to  intestinal  ulcer,  a  single  band  passes  between 
two  neighbouring  coils  of  intestine.  The  early  stage  of  such 
a  band  is  well  shown  in  Fig.  82. 

Among  the  less  usual  attachments  of  these  b;^nds  may 
be  mentioned  the  following :  Between  the  descending  colon 
and  the  mesentery. §  Between  the  mesentery  near  the 
c;ifcum,  and  the  anterior  surface  of  the  rectum. ||  Between 
the  transverse  colon  and  the  caecum^  (the  band  in  this 
case  occurred  in  connection  with  extensive  adhesions  due 
to  peritonitis  after  ulcer  of  the  stomach).  Between  the 
/ 

*  University  Coll.  Museum,  No.  1161. 

t  See  specimens  at  St.  Bart.'s   Hosp.  Museum,  No.  2165;  and  Lond.   Hosp. 
Jluseiiin,  No.  Ad.  79. 
t  No.  1360a. 

§  St.  Thomas's  Hosp.  Museum,  No.  R  15. 
II   Mr.  Ward;  Path.  Soc.  Tr.ns.,  1852,  p.  362. 
IT  Dr.  Hilton  Fagge  ;  Guy's  Mosp.  lieports,  vol.  xiv.,  1869,  p.  272. 


36  MORBID    ANATOMY. 

■ymentum  and  the  mesentery.*      Between  the  ascending  and 
descending  colon. f     Between  the  colon  and  the  ovary.J 

In  not  a  few  cases  isolated  cords  ot  adhesion  are  described 
as  passing  between  the  sigmoid  flexure  and  distant  parts.  In 
this  way  the  flexure  has  been  connected  with  the  csecum,  with 
the  mesentery  near  the  csecum,  and  with  the  parietal  perito- 
neum in  the  right  iliac  fossa.  Rokitansky§  reports  a  case  of 
adhesion  between  the  sigmoid  flexure  and  a  coil  of  small  in- 
testine in  the  right  hypochondriac  region.  It  is  well  known 
that  the  distended  sigmoid  flexure  may  reach  the  right  iliac 
fossa,  or  even  the  right  hypochondriac  district,  and  cases  like 
the  above  may  be  explained  on  the  assumption  that  the 
flexure  became  greatly  distended  during  the  time  that  the 
jjeritonitis  w'as  active  from  which  the  adhesions  were  derived. 

Methods  of  Strangulation. — When  a  portion  of  the  in- 
testine is  strangulated  by  an  isolated  peritoneal  adhesion  the 
gut  will  be  found  to  be  constricted  in  one  of  two  ways.  1.  It 
may  be  strangulated  beneath  the  band  as  beneath  a  shallow 
and  narrow  arch.  2.  It  may  be  snared  and  constricted  by  a 
noose  or  knot  formed  by  the  false  ligament  itself 

].  Stra'tig Illation  beneath  a  bavd  can  only  occur  when  the 
band  is  comparatively  short,  and  when  it  is  stretched  along  a 
firm  surface.  From  an  examination  of  some  fifteen  cases, 
where  the  constricting  cord  is  well  described,  it  would  appear 
that  its  average  length  in  this  form  of  strangulation  is  about 
one  and  a  half  to  two  inches.  The  arch  beneath  which  the 
implicated  bowel  passes  is  variously  described  as  large  enough 
to  admit  one,  two,  or  three  fingers.  Larger  arches  have  been 
formed  permitting  much  intestine  to  pass  beneath  them,  but 
tliese  great  apertures  are  exceptional  in  acute  cases.  Since 
the  cord  must  be  stretched  along  a  firm  surface  it  happens 
that  this  form  of  strangulation  is  much  more  commonly  found 
about  the  posterior  abdominal  parietes  than  elsewhere.  It  is 
often  met  with  about  the  iliac  fossie,  especially  that  of  the 
right  side,  and  about  the  brim  of  the  true  pelvis.  When  a 
band  passes  between  two  points  on  the  mesentery  a  coil  of 
small  intestine  may  readily  be  strangulated  beneath  it,  the 
resisting  parts  between  which  the  bowel  is  compressed  being 
the  fabe  ligament  on  the  one  hand,  and  the  mesentery  on  the 
other.  It  will  be  readily  understood  also  that  a  knuckle  of  the 
small  intestine  may  be  strangulated  with  little  difficulty  when 
it  passes  between  a  band  and  a  solid  viscus  like  the  uterus. 

*  Dr.  Hilton  Fagije,  loc.  cit. 

t  Seerig;  Rust's  Magazin  fiir  Heilkuiifie,  band  xlvi. 

X  RokitHnsky  ;  Brit,  and  For.  Med.-Chir.  Review,  vol.  iii. 

§  Mauual  uf  Path   Anatomy  (Syd.  Soc),  vol.  ii. ,  1850. 


STRANGULATION   BY   BANDS. 


37 


Fia.  8. 


In  some  few  cases  the  firm  basis  required  for  this  form  of 
obstruction  appears  to  have  been  provided  by  a  rigid  mass  of 
adhesions,  across  which  the  false  hgament  has  been  stretched 

A  loop  caught  beneath  a  band  is 
very  apt  to  undergo  rotation,  and  such 
twist  or  volvulus  may  contribute  more 
to  the  actual  obstruction  of  the  bowel 
than  does  the  band  which  represents 
the  strangulating  agent.  The  bowel 
so  snared  and  twisted  may  become  untwisted  and  escape. 

2.  Strangulation  by  a  noose  or  knot  requires  a  long  false 
ligament  which  must  lie  loose  and  free  in  the  abdominal 
cavity,  being  attached  only  by  its  two  ends. 

The  snaring  of  a  coil  of  small  intestine  by  this  means 
nmst  be  a  matter  of  some  difficulty,  and  must  be  almost 
impossible  in  cases 
where  the  bowel  is 
perfectly  normal.  As 
Leichtenstern  has  well 
pointed  out,  the  gut  in 
these  cases  will  usually 
be  found  to  have  been 
in  an  abnormal  con- 
dition previous  to  the 
occurrence  of  the 
strangulation.  A 
knuckle  of  gut  may  be 
rendered  so  adherent 
that  it  could  not  slip 
out  of  the  way  by 
peristaltic  movement 
when  it  had  become 
involved  in  the  noose 
or  knot.  It  is  probably 
a  still  more  common 
circumstance  for  two 
ends  of  a  loop  of  in- 
testine to  be  matted 
together  by  a  little 
mesenterial  peritonitis, 
so  that  if  the  noose 
should  slip  over  such 
a  loop,  the  constricting 
cord  will  find  at  the 
base  of  the  loop  a  nar- 
rowed    neck      around 


Fia.  9. 


-Straiigulatinn  by  a  Band. 
{Astlei/  Cooper.) 


anterior  abdominal  parietes  ;  b,  band  passing  from  a 
lieriiial  sac  to  surround  tlie  intestine  ;  c.  bind  return- 
ing to  the  hernial  sae  ;  d,  loop  or  noose  lorMie<l  by 
the  band;  e,  intestine  strangulated  by  Uie  noose  d; 
f,  intestine  strangulated  in  a  less  degree  by  the  ynti- 
tions  of  tlie  baud  b  and  c. 


3S 


MORBID   ANATOMY. 


which  it  may  take  hold.  The  most  common  method  whereby 
a  coil  of  intestine  may  be  snared  is  when  the  lax  band  forms  a 
ring  or  spiral  between  its  tixed  points  a  and  h  (Fig.  8). 
Through  this  ring  a  loop  of  the  small  intestine  slips,  or  over 
an  abnormally  fixed  coil  of  that  part  of  the  bowel  the  noose 
passes.  For  an  excellent  illustration  of  this  method  see  Fig.  9.* 
Strangulation  by  the  formation  of  a  knot  is  somewhat 
ditf'erent  from  the  process  of  snaring  just  described.  The 
mechanism  of  this  variety  of  obstruction  is  thus  described 
by  Leichtenstern :  "  There  are  several  kinds  of  this  knotting. 
The  most  frequent  is  the  following:  The  long  and  loose 
ligament  is  fastened  at  one  end  to  a  loop  of  the  small 
intestine,  and  hangs  in  the  form  of  a  simple  coil  (Fig.  10). 
If  the   top   of  the   intestinal  loop   passes  directly   through 


Fig.  11. 


Fig.  12. 


the  coil  c,  a  simple  knot  is  formed  about  the  piece  of  the 
intestine,  as  is  shown  in  Fig.  11.  It  is  evident  that  the  same 
result  can  be  produced  by  the  coil  being  thrown  over  the 
top  of  and  around  the  intestinal  loop. 

"  Another  and  rarer  form  of  knot  is  made  as  follows : 
a  long  and  perfectly  loose  false  ligament  forms  a  simple 
coil,  like  that  shown  in  Fig.  8,  between  its  points  of  attach- 
ment a  and  h.  If  now  one  leg  of  the  so-called  primary 
noose  passes  through  it  Ave  have  a  knot  like  that  shown 
in  Fig.  12,  and  if  now  the  intestinal  loop  passes  directly 
through  c  (Fig.  12),  it  becomes  firmly  caught  and  strangu- 
lated. 

"A  common  characteristic  of  all  described  knots  is  that 
when  the  strangulated  intestine  is  freed  the  ligament  can 
immediately  be  drawn  out  straighc."t 

With  regard  to  the  relative  frequency  of  these  two  forms 

*  From    Sir   Aslley   Cooper's   Treatise   on  Abdominal  Hernia,  plate  xxvi., 
l'i!,'s.  2  arid  3. 

■)•  Sir  A.  Cooper:  Ic.  cit.,  p.  52S. 


STRAXGULATIOX   BY    OMENTAL    CORDS.  39 

of  strangulation  by  band,  viz.  strangulation  under  the  false 
ligament,  and  strangulation  by  a  noose  or  knot,  m}^  own 
collection  of  cases  gives  the  proportion  of  the  two  as  about 
eight  to  one.  Leichtenstern,  however,  who  deals  with  a 
larger  series  of  instances,  has  tabulated  lifty-six  cases  of 
strangulation  under  the  band,  and  twenty-six  by  means  of 
knots  and  snaring. 

With  regard  to  the  amount  of  intestine  which  may  be 
involved  in  a  noose  or  knot,  it  must  be  remembered  that 
the  false  ligament  may,  in  certain  circumstances,  attain  a 
considerable  length.  Thus,  in  Mr.  Obre's  case  already  alluded 
to  (page  29),  the  false  ligament  was  17i  inches  long. 

Into  the  precise  physical  conditions  that  underlie  the 
])roduction  of  strangulation  in  these  and  in  analogous  forms 
of  strangulation  it  is  not  necessary  to  enter. 

An  excellent  account  of  the  mechanism  of  strangulation 
as  applied  to  hernia  has  been  given  by  Schmidt,'^  and  an 
able  account  of  the  various  theories  which  exist  upon  the 
question  has  been  furnished  by  Hueter.f  To  the  works  of 
these  authors  the  reader  is  referred. 

2.  Strangulation  by  Cords  formed  from  the  Omentum. 
— These  cords  are  in  all  cases  due  to  an  adhesion  or  ad- 
hesions formed  between  the  omentum  and  some  other 
peritoneal  surface  as  a  consequence  of  peritonitis. 

The  form  and  arrangement  of  these  omental  cords  show 
very  considerable  variety.  Sometimes  the  lower  border  of 
the  omentum,  and  probably  the  central  part  of  that  border, 
becomes  adherent  at  some  one  spot.  As  a  result  the  inferior 
part  of  the  membrane  is  rolled  up  into  a  round  solid  band, 
and  the  whole  structure  assumes  a  fan-shaped  outline.  The 
ba^e  of  the  fan  is  at  the  transverse  colon,  while  its  apex 
or  narrowed  part  is  represented  by  the  cord-like  extremity 
of  the  adherent  epiploon.  A  case  of  this  character  is  reported 
by  Dr.  Hare,  the  point  of  adhesion  being  at  the  anterior 
abdominal  parietes  below  the  umbilicus.  J  In  a  somewhat 
siinilar  case  reported  by  Mr.  Avery  the  extremity  of  the 
omentum  was  twisted  into  a  cord  about  the  size  of  the 
little  finger,  and  attached  to  the  mesentery  in  the  right 
iliac  reoion.S 

In  other  cases,  especially  where  one  of  the  lateral  borders 

*  Die  UnterleiKsbriic'ie.  Handb.  der  Allgem.  und  Speciel.  Chirurgie, 
Von  Pitha  und  Billrnih,  1882,  p.  146. 

t  G-rundries  der  Chirurgie,  p.  248.     Leipzig,  1883. 

J  Path.  8oc.  Trans.,  vol.  in.,  1851,  p.  111. 

§  Ibid.,  vol.  iv.,  p.  156.  A  case  of  a  like  character  will  he  found  in  a  pnper 
bv  M.  Berger,  in  Bull,  et  Mem.  de  la  Soc.  de  Chii-.  de  Paris,  tome  vi.,  1880, 
p.  601. 


40  MORBID   ANATOMY. 

of  the  epiploon  has  become  adherent,  the  attached  portion 
separates  as  a  cord,  which  becomes  in  time  dense  and  fibrous. 
If  the  omentum  has  formed  extensive  adhesions,  its  whole 
substance  may  be  changed  into  a  series  of  cords  passing 
between  the  transverse  colon  and  various  other  parts  of 
the  abdominal- cavity.  Such  was  the  condition  of  things, 
jbr  example,  in  a  case  of  Dr.  Fagge's,  the  many  false  liga- 
ments that  had  formed  being  attached  to  the  abdominal 
parietes  and  small  intestines  in  many  places."^  In  any  case 
the  omentum  from  which  a  band  is  derived  is  often  found 
much  altered  in  structure,  having  become  thin  and  reticulate. 

One  of  the  most  curious  modes  of  forming  omental  bands 
is  met  with  in  a  case  described  by  Dr.  K.  Fowler,  f  Here 
the  epiploon  was  divided  into  two  lateral  cords,  which,  coming 
off  from  either  side  of  the  transverse  colon,  passed  down 
behind  or  among  the  intestines,  and  were  found  to  be  united 
together  near  the  pelvis.  All  the  patient's  troubles  dated 
irom  a  kick  received  upon  the  abdomen.  It  is  probable  that 
in  this  case  a  rent  had  formed  in  the  omentum,  througli 
Avhich  the  great  bulk  of  the  small  intestines  had  protruded. 
The  lateral  parts  of  the  omentum,  i.e.  the  parts  on  both 
sides  of  the  rent,  had  then  shrunken  into  cord-like  masses, 
which  would  be  more  or  less  hidden  by  the  bowels.  I  Jr. 
Hilton  Fagge  has  put  upon  record  an  almost  similar  case 
in  his  monograph  in  the  Guy's  Hospital  Reports. 

When  once  a  portion  of  the  epiploon  has  become  adherent 
the  development  of  the  attached  part  into  a  ligamentous 
cord  is  to  be  explained  by  the  same  process  that  fashions 
a  broad  ribbon-like  adhesion  into  a  hbrous  thread.  The 
segment  of  the  adherent  omentum  is  continually  being 
(h-agged  upon,  especially  when  attached  to  a  movable  viscus ; 
it  tends  to  become  elongated,  while  the  rolling  movements  of 
the  bowels  around  it  help  to  mould  it  into  a  rounded  cord- 
like ligament.     (See  page  29.) 

As  a  rule,  the  omental  cords  are  much  coarser  and  thicker 
than  are  the  bands  resulting  from  peritoneal  adhesions. 
Many  are  nearly  as  thick  as  the  finger,  while  only  a  few 
are  described  as  being  very  fine.  In  the  matter  of  length  they 
usually  have  an  advantage  over  the  simple  band,  as  may 
l:e  expected  from  the  dimensions  and  relations  of  the  great 
omentum. 

The  point  of  attachment  of  the  epiploic  band  will 
obviously  depend  upon  the  situation  of  the  peritonitis, 
which  renders  it  adherent.     Such  adhesion  may  follow  after 

*  Gnv's  Hosp.  Reports,  loc.  cit. 
t  Path.  Soc.  Trans.,  1882,  p.  146. 


STRANGULATION    BY   OMENTAL    CORDS.  41 

any  form  of  peritoneal  infiammation  from  which  a  patient 
recovers. 

It  may  be  due  to  a  Hmited  peritonitis  following  injury, 
as  in  Mr.  Avery's  case  mentioned  above,  where  the  attach- 
ment was  close  to  a  slit  in  the  mesentery,  the  result  ot 
violence.  Pelvic  peritonitis  may  lead  to  adhesions  in  and 
about  the  pelvis,  and  from  this  cause  the  omentum  has 
been  found  connected  with  the  uterus  or  the  ovaries.  In 
like  manner  perityphlitis  very  often  leads  to  attachments 
to  the  ctecum  and  to  the  peritoneum  in  the  iliac  fossa.  In 
other  and  less  well-defined  instances  the  abnormal  attach- 
ment has  been  found  upon  the  mesentery  and  upon  the 
free  surface  of  the  small  intestine.  Undoubtedly,  however, 
the  most  common  cause  of  omental  adhesion  is  some 
peritonitis  set  up  about  a  hernia,  and  especially  about  a 
femoral  hernia."^  The  frequency  with  which  omentum  is 
found  in  the  latter  form  of  rupture  is  well  known,  as  is 
also  its  disposition  to  become  adherent  when  once  so  pro- 
lapsed. Thus  it  happens  that  the  most  frequent  point  for 
the  attachment  of  an  omental  band  is  in  the  vicinity  of 
the  femoral  ring.  Since  the  omentum  lies  more  to  the  left 
than  to  the  right  side  of  the  abdomen,  omental  hernise  are 
more  common  upon  the  left  side,  and  it  is  therefore  about 
the  hernial  orifices  to  the  left  of  the  middle  line  that  the 
omental  cords  are  more  usually  attached. 

One  of  the  least  common  aspects  of  the  epiploic  cord 
is  shown  in  a  specimen  in  St.  Thomas's  Hospital  Museum, 
in  which  it  will  be  seen  that  the  cord  passes  merely  from 
one  part  of  the  great  omentum  to  another. 

While,  as  above  stated,  only  one  peritoneal  false  ligament 
is  usually  found  in  a  given  instance,  the  omental  adhesions 
may  be  met  with  in  the  form  of  two  or  even  more  cords. 
In  the  case  of  epiploic  adhesions  also  two  cords  may  be 
found  apparently  constricting  the  bowel  at  different  points, 
and  in  performing  laparotomy  for  the  relief  of  such  obstruc- 
tion the  wrong  band  may  be  divided.  This  circumstance 
happened  to  Mr.  Bryant.  He  had  divided  an  omental  band 
attached  to  the  left  ovary  which  appeared  to  be  obstructing 
the  gut,  but  at  the  autopsy  a  second  cord  was  found  con- 
nected with  the  uterus,  beneath  which  was  a  coil  of  ileum 
tightly  strangulated. t 

The  modes  of  strangulation  by  omental  cords  are  identical 
with    those   described   in  connection  with   peritoneal   bands, 

*  Portions  of  omentum  attached  to  umbilical  heiniae  rarely,  if  ever,  forai 
acrnal  cords. 

f  St.  Thomas's  Ho^p.  Museum,  No.  R  H. 


42  MORBID    ANATOMY. 

although  the  proportion  of  cases  of  strangulation  by  a 
noose  or  knot  is  greater  in  the  former  than  in  the  latter 
class  of  adhesion.  This  circumstance  is  no  doubt  due  to 
the  greater  average  length,  and  the  greater  mobility  of  the 
omental  false  ligament.* 

3.  Strangulation  by  Meckel's  Diverticulum. — The  true 
or  Meckel's  diverticulum  is  due  to  the  persistence  or  in- 
complete obliteration  of  the  vitelline  or  omphalo-mesenteric 
duct.  It  occurs  in  about  2  per  cent,  of  the  bodies  examined, 
and  is  a  little  more  common  in  males  than  in  females.  When 
met  with  in  its  most  perfect  condition  it  exists  as  a  tube, 
having  a  structure  similar  to  that  of  the  small  intestine 
itself,  and  extends  between  the  lower  part  of  the  ileum  and 
the  umbilicus.  The  abdominal  end  of  the  tube  opens  into 
the  lumen  of  the  lesser  bowel,  while  the  umbilical  extremity 
may  be  closed,  or  may  open  upon  the  surface  and 
permit  of  the  free  discharge  of  fsecal  matter.  I  have  myself 
met  with  two  cases  where  such  discharge  took  place.  Once 
in  a  lad,  ao'ed  seventeen,  who  had  been  troubled  since  birth 
with  the  occasional  escape  of  faeces  from  a  smus  at  the 
navel,  and  once  in  a  male  infant  a  few  weeks  old,  where 
a  like  condition  existed,  and  upon  whom  I  successfully 
performed  a  plastic  operation  for  the  closure  of  the 
abnormal  passage. 

Mr.  Bernard  Pittsf  reports  a  case  in  which  a  fsecal  dis- 
charge at  the  umbilicus,  due  to  a  Meckel's  diverticulum, 
appeared  when  the  child  was  three  weeks  old,  persisted  for 
seven  years,  and  then  ceased  spontaneously. 

The  opening  at  the  umbilicus  may  be  so  wide  that  the 
mucous  membrane  of  the  diverticulum  may  prolapse  and 
form  a  spur,  on  either  side  of  which  will  be  a  very  apparent 
opening  into  the  ileum. 

These  conditions,  however,  of  the  diverticle  are  com- 
paratively rare.  Most  commonly  it  exists  as  a  blind  tube 
coming  off'  from  the  ileum.  The  length  of  this  tube  is  on  an 
average  two  to  three  inches,  and  in  the  great  majority  of  the 
examples  the  measurement  extends  between  one  inch  and 
four.  Sometimes  it  exists  only  as  a  nipple-like  projection.;!: 
On  the  other  hand  cases  are  recorded  where  the  diverticle,  in 
the  form  of  a  free  tube,  attained  the  length  of  ten  inches.  As 
a  rule  the  abaormal  tube  is  cylindrical  in  shape,  with  a  conical 
extremity.  In  nearly  every  instance  the  intestinal  end  of  the 
diverticulum  is  larger  than  its  opposite  extremity. 

*  La.7icet,  vol.  ii.,  1873,  p.  773. 

t  Trans.  Path.  Soc,  vol.  xxxiii.,  p.  145. 

X  Guy's  Hosp.  Museum,  No.  1819  (45). 


STRANGULATION   BY   MECKEL'S    DIVERTICULUM.     43 

In  only  very  rare  instances  has  it  been  seen  to  assume  a 
polypoid  form  and  present  a  comparatively  narrow  attach- 
ment. Kelynack*  figures  such  a  diverticulum.  The  diameter 
at  the  point  of  junction  with  the  ileum  was  three  quarters  of 
an  inch.  Its  terminal  point  formed  a  large  pouch  with  a 
diameter  of  three  and  a  quarter  inches. 

In  diameter  its  base  is  usually  less  than  that  of  the  gut 
from  whence  it  arises,  although  sometimes  the  diameters  of 
the  two  tubes  may  be  nearly  identical.t  It  may  retain  the 
same  width  throughout,  and  thus  resemble  a  glove  linger. 
Much  more  frequently,  however,  its  free  extremity  is  con- 
siderably narrower  than  its  base. 

In  structure  the  diverticulum  is  composed  of  all  the  layers 
of  normal  small  intestine.  Its  mucous  membrane  is  smooth, 
and  possesses  Lieberkiihn's  follicles.  It  often  presents  also  a 
Peyer's  patch  (Cazin).  The  muscular  coat  is  sometimes 
deficient  at  the  apex  of  the  diverticle,  and  at  this  spot,  there- 
fore, hernial  protrusions  of  the  mucous  membrane  under  the 
serous  coat  are  not  infrequently  met  with.  When  this  occurs 
the  extremity  of  the  abnormal  tube  presents  an  ampulla  of 
globular  shape,  and  the  process  is  said  to  be  "  clubbed."  The 
end  may  appear  bifid.  In  one  dried  preparation  in  the 
London  Hospital  Museum  the  ampulla  at  the  end  of  a  diverti- 
cuhim  has  so  peculiar  an  outline  that  the  whole  process, 
which  is  of  no  great  length,  looks  hammer-shaped.  A  like 
specimen  is  figured  by  Hudson  in  the  Pathological  Society's 
Transactions  for  1889.  The  clubbed  extremity  of  the  di- 
verticulum, when  it  exists,  takes  an  important  part  in  the 
production  of  strangulation  by  knotting.  In  cases  where  the 
diverticulum  appears  as  a  comparatively  immense  pouch  there 
is  Httle  doubt  but  that  the  process  has  been  exposed  to  a  con- 
siderable degree  of  distension.  Cazin  figures  a  case  where  a 
species  of  valve  or  diaphragm  existed  between  the  diverticulum 
and  the  intestine.|     Meckel  alludes  to  a  similar  arrangement. 

The  diverticulum  is  always  single,  and  arises  from  tlie 
ileum  from  fifteen  to  thirty-six  inches  above  the  ileo-csecal 
valve.  It  is  rare  for  the  process  to  take  origin  beyond  these 
limits.  Indeed  the  average  distance  of  the  diverticulum  from 
the  ileo-cascal  valve  is  three  feet.  Cazin,  however,  alludes  to 
a  case  where  it  is  said  to  have  arisen  from  the  ileum,  twent}^ 
fines  from  the  cfficum.  In  a  specimen  in  Guy's  Hospital 
Museum  §  the  process  is  described  as  springing  from  the 
middle  of  the  ileum. 

*  Brit.  Med.  Journ.,  Aug-.  21,  1897.  t  For  an  instance  of  a  very  wide 
dive'-'iculum,  set  specimen  No.  1819  (50),  in  Guy's  Hosp.  Museum. 

+  Elude  sur  les  Diverticules  de  I'lntestin.    Paris,  1862.     §  No.  1819  (50). 


44  MORBID    ANATOMY. 

The  diverticulum  always  arises  from  the  side  of  the  gut 
most  remote  from  the  mesentery. 

It  is  a  question  whether  those  elongated  diverticula  which 
are  described  as  growing  between  the  layers  of  the  mesenterv 
are  real  instances  of  Meckel's  process.  These  rare  forms  are 
alluded  to  below  (page  56). 

The  process  may  come  off  at  an  acute  angle  with  the  long 
axis  of  the  bowel,  but  more  usually  the  angle  formed  is  a 
ritrht  anjyle. 

It  is  sometimes  provided  with  a  scanty  mesentery,  as  is 
shown  in  a  drawing  by  Sandifort. 

The  end  of  the  diverticulum  is,  in  the  majority  of  cases, 
free.  Very  often,  however,  it  is  continued  in  the  form  of  a 
solid  cord.  This  cord  should  be  attached  to  the  umbilicus 
or  to  the  abdominal  parietes  immediately  below  that  cica- 
trix."^ This  attachment  is,  indeed,  very  frequently  met  with. 
Often  the  cord  is  pervious  for  a  little  way,  and  presents  a 
minute  canal  in  which  a  bristle  may  be  inserted.  This  di- 
verticular ligament  may  break  from  its  attachment  to  the 
parietes  and  may  float  free  within  the  abdominal  cavity. 
In  such  circumstances,  however,  it  is  much  more  usual 
for  it  to  acquire  fresh  adhesions  to  some  point  of  the  peri- 
toneal surface. 

These  secondary  adhesions  of  a  free  diverticulum,  or  of 
a  diverticular  cord  at  the  extremity  of  one  of  the  processes, 
are  of  considerable  importance  in  the  etiology  of  strangula- 
tion  of  the  intestine.  It  is  by  the  diverticulum  that  has 
acquired  a  iresh  point  of  attachment  that  constriction  of 
the  bowel  is  most  often  effected.  It  is,  in  the  great  majority 
of  cases,  to  the  mesentery  that  the  tube  or  the  cord  continued 
from  it  is  adherentf  This  adhesion  may  be  found  on  a 
portion  of  the  mesentery  above  the  origin  of  the  diverticu- 
lum, but  somewhat  more  frequently  it  is  on  the  mesentery 
of  the  ileum  between  the  point  of  origin  of  the  process  and 

*  St.  Bart.'s  Hosp.  Museum,  No.  2168,  and  many  other  specimens, 
t  In  twenty-thne  cases  collected  by  Cazin    tlie  points  uf    attachment  of 
the  diverticulum  were  as  follows  : 


Near  umTiilicus        ...  ...  3 

Near  inguinal  ring...  ...  1 

To  small  gut  ...  ...  (> 

To  csecum     ...         ...  ...  2 


To  colon       ...         ...         ...       1 

To  mesentery  ...         ...     10 

23 


In  twenty   additional   cases  collected   by  myself  the  attachments  were  as 
follows : 


Near  umbilicus  ...  ...  7 

To  femoral  ring  ...  ...  1 

To  small  gut  ...  ...  8 

To  Oiccum    ...  ..,  ...  1 


To  mesentery  ...  ...        7 

To  the  bladder         ...  ...        1 

20 


STRANGULATION   BY   MECKEL'S    DIVERTICULUM.     45 

the  caecum.  Not  infrequently  the  attachment  to  the  mesentery 
is  at  the  spot  occupied  by  diseased  mesenteric  glands. 

I  have  found  the  diverticular  ligament  adherent  to  the 
bladder 

The  loop  formed  by  such  an  adhesion  presents  the  gTeatest 
possible  variety.  When  the  diverticulum  is  very  small  and 
short,  the  ring  that  it  forms  is  quite  insignificant,  and  in- 
capable of  engaging  more  than  a  slight  portion  of  the 
intestine.*  A\^hen,  however,  the  process  is  long,  and 
especially  where  it  ends  in  an  elongated  cord  or  ligament, 
a  loop  of  considerable  size  may  be  formed,  and  nooses  and 
knots  may  be  developed  capable  of  snaring  many  coils  of 
the  bowel,  t 

In  other  cases  the  diverticle  or  diverticular  cord  is 
attached  to  some  other  part  of  the  small  intestine  or  to 
the  omentum,  or  to  some  point  on  the  abdominal  parietes 
other  than  the  immediate  vicinity  of  the  umbilicus.  In 
many  instances  it  is  evident  that  the  site  of  the  adhesion 
has  been  influenced  by  some  definite  form  of  localised 
peritonitis.  Thus  the  extremity  of  the  diverticulum  has 
been  found  attached  to  the  pelvic  viscera  or  pelvic  parietes 
after  peritoneal  inflammation  in  that  region,  to  the  c^cum 
or  peritoneum  about  the  right  iliac  fossa  after  perityph- 
litis, and  to  the  vicinity  of  the  femoral  and  inguinal  canals 
after  hernia.  In  some  specimens  the  peritonitis  causing  the 
adhesion  has  evidently  been  set  up  by  mesenteric  gland 
inflammation,  as  already  mentioned. 

In  another  series  of  cases  the  diverticulum  does  not 
exist  as  such,  but  is  replaced  in  its  entire  length  by  a 
fibrous  cord  identical  in  aspect  with  the  band  so  often 
seen  attached  to  the  apex  of  the  tubular  process.  These 
cords  may  be  found  to  extend  between  the  parietes  in  the 
vicinity  of  the  umbilicus  and  that  part  of  the  ileum  from 
which  the  more  familiar  diverticle  takes  origin.  They  may 
be  considered  to  represent  an  entirely  obliterated  diverti- 
culum, or  may  be  the  remains  of  persisting  omphalo- 
mesenteric vessels.  J  A  case  belonging  to  the  latter  category 
has  been  placed  on  record  by  Dr.  Mahomed.  In  this  instance 
a  fibrous  band  extended  from  the  middle  of  the  anterior 
abdominal  wall  (midway  betAveen  the  os  pubis  and  the 
umbilicus)  to  the  right  iliac  fossa.  The  deeper  extremity 
of  the  cord  had  snared  in  a  noose  a  large  portion  of  ileum. 

*  Guy's  Hosp.  Mufeum,  No.  1819  (36). 
+  Path.  Soc.  Trrnis.,  vol.  xxi.,  p.  185. 

J   See  exhniistive  paper  on  Pcrjisstent  Omph;ilo-JIe3.  Remains,  by  Dr.   Fitz 
Amn;  J.  of  Med.  Sc,  July,  1884. 


46  MORBID    ANATOMY. 

It  then  attached  itself  to  the  mesentery,  some  three  feet 
from  the  ileo-cfecal  valve,  and  was  found  to  be  continuous 
with  a  branch  of  the  ileo-colic  artery.  The  more  superficial 
extremity  of  the  band  divided,  one  part  ascending  to  the 
navel  with  the  obliterated  hypogastric  artery,  the  other 
descending  to  form  the  left  superior  vesical  artery.  The 
cord  was  quite  impervious  to  injection.^ 

These  diverticular  ligaments  may  break  loose  from  their 
connections  at  the  umbilicus,  and  may,  like  the  tubular 
]3rocesses,  either  remain  free  in  the  abdominal  cavity,  or 
form  secondary  adhesions  at  almost  any  spot. 

To  complicate  this  matter  still  further,  the  cord  may 
retain  its  attachment  to  the  anterior  abdominal  wall,  and 
separate  from  its  connection  with  the  intestine.  It  may 
then  either  form  no  other  attachment,  or  may  adhere  to 
a  point  somewhere  within  the  abdomen.f 

Finally,  a  cord  may  be  found  to  stretch  from  the  root 
of  the  mesentery  to  be  attached  to  the  margin  of  the 
ileum  (close  to  its  mesentery)  opposite  the  spot  from  which 
the  diverticle  most  commonly  arises.  Leichtenstern  believes 
that  such  bands  represent  that  part  of  the  omphalo-mesen- 
teric  vessels  which  extends  between  the  bowel  and  the  main 
blood-vessels  at  the  root  of  the  mesentery.  He  gives  a 
figure  to  show  the  continuation  of  this  band  with  an  ordinary 
diverticulum  which  is  attached  by  a  cord  to  the  umbilicus. 
A  false  ligament  described  by  Dr.  David  King  may  possibly 
have  been  of  this  nature.  This  band,  Avhich  was  an  eighth  of 
an  inch  in  diameter,  passed  from  the  upper  part  of  the  root  of 
the  mesentery  to  a  point  on  the  small  intestine.  Beneath  it  a 
piece  of  bowel  had  become  strangulated.  J 

There  can  be  little  doubt  but  that  these  strangely  attached 
diverticular  ligaments  have  very  often  been  mistaken  for 
isolated  peritoneal  adhesions  ;  and,  in  any  case,  where  a 
"  solitary  band  "  exists  without  a  trace  of  ancient  peritonitis, 
there  are  substantial  grounds  for  suspecting  the  cord  to  bo 
of  congenital  origin. 

The  diverticulum,  as  already  stated,  is  always  single. 
The  same  remark  applies,  with  but  few  exceptions,  to  the 
diverticular  ligaments.  In  a  few  instances  the  cord  seems 
to  have  divided,  so  that  an  appearance  as  of  two  bands 
was  produced.  Such  is  apparently  the  case  in  a  specimen 
in    one   of  the  museums,  §   in  which  one  ligament  encircles 

*  Path.  Soc.  Trans.,  vol,  xxvi.,  p.  47. 

t  Spangenber<):  ;  Aich.  f.  Phys.  v.  Meckel,  b.  v.,  8.  87. 

I  fit.  Bart.'s  Hosp.  I-.'eports,  vol.  xvii.,  1881,  p.  277. 

§  yt.  Bart.'s  Hosp.  Museum,  No.  2173. 


STRANGULATION   BY   MECKEL'S    DIVERTICULUM.     47 

a  loop   of  bowel   and   strangulates  it,  while  the  other  goes 
to  be  attached  to  the  vicinity  of  the  femoral  ring. 

It  may  be  here  mentioned  that  a  free  true  diverticiilimi 
has  in  several  instances  been  found  in  an  external  hernia. 
One  of  the  earliest  cases  of  this  kind  is  described  by  Littre."^ 
In  this  case  a  diverticle  four  inches  in  length  was  found  in 
a  scrotal  hernia  in  a  man  aged  forty-eight.  It  is  evident  that 
Littre  was  unaware  of  the  nature  of  the  intestinal  pouch,  t 
Cazin  gives  a  drawing  to  show  a  Meckel's  diverticulum  m 
a  scrotal  hernia  from  a  case  dissected  by  himself.  1 

Methods  of  Producing  Strangulation. — 1.  Strangula- 
tion as  by  a  Band. — A  coil  of  small  intestine  may  be 
strangulated  beneath  an  adherent  diverticulum  precisely  in 
the  same  manner  as  it  would  be  when  beneath  a  peritoneal 
adhesion.  An  illustration  of  this  mode  of  constricting  the 
bowel  is  shoAvn  in  Fig.  13  from  a  case  reported  by  M,  Eayer.  § 
It  is  scarcely  possible  to  conceive  that  this  method  of 
producing  obstruction  can  occur  when  the  diverticulum 
simply  extends  between  the  ileum  and  the  anterior  abdominal 
wall.  Yet  several  cases  are  recorded  where  the  diverticulum 
had  these  attachments,  and  where  it  is  stated  that  beneath 
ihe  process  some  bowel  was  strangulated. 

It  is  probable  that  the  bowel  so  engaged  had  become 
twisted  upon  itself,  and  that  its  lumen  had  been  closed  by 
the  volvulus  rather  than  by  the  adherent  ^^      ,    cl 

process.  f  IJl     ■   Vf 

In    nearly   all    reported    instances    of    '^  I'  /"^^^^r^  J  '^ 
strangulation   under   a   diverticulum,    the        T  KS\^  f 
process  has  been  adherent  to  a  point  other     i-^^^^w^S'^ 
than  the  vicinity  of  the  umbilicus.     When  /i^^'^^^ 

the  adhesion  is  to  the  mesentery,  as  is  so  ^^^^Zdn^ 

frequently    the    case,    it    will   be    readily  ^2?-^''-^ 

understood   that   beneath    the   arcade    so    '^^^tioi^^ansdhereut 
formed  a  loop  of  intestine   may  be   with         Divenicie  [Rayer). 
great  ease  engaged  and  compressed.     This    «,  I'PP'-r  end  of  gut ;  &, 
condition  of  the  parts  is  often  met  with.  co7nn;^rf,  tiie°diver- 

It  is  common   for   the  bowel  beneath         litla'ioop.^^  strangu- 
the  adherent  diverticle  to  be  twisted  upon 
itself     Dr.  Hector  Mackenzie  ||  reports  a  case  in  which  five  to 
six  leet  of  ileum  were  thus  twisted,  and  actually  strangled. 

*  Mem.  de  I'Acad.  des  Sciences,  1700,  p.  300,  "  Observat.  sur  une  noavelle 
Espece  de  Hernio." 

t  A  full  account  of  the  relation  of  the  diverticulum  to  hernia  will  be  found 
in  "  Du  Pincement  Hernihre  de  I'lntestin,"  hy  M.  Loviot.     Paris,  1879. 

X  Loc.  cit.,  Fig.  14.  See  also  case  by  Biisch,  Central,  fiir  Chiiurg.,  1884. 
No.  23,  p  69. 

\  Aichiv,  Gen.  de  Med.,  tome  v.,  p.  68.      |i  Path.  See.  Trans.,  1890,  p.  127, 


48 


MORBID    ANATOMY. 


2.  Strangulation  hy  a  Noose. — A.  diverticular  ligament, 
whether  attached  to  the  extreniity  of  a  pouch-like  process. 
or  (in  the  absence  of  such  process)  connected  directly  with 
the  gut,  may  form  precisely  the  same  kinds  of  noose  and 
knot  as  are  formed  by  isolated  adhesions.  The  length  and 
looseness  of  the  congenital  ligament  render  it  well  able  to 
snare  the  bowel,  provided  that  the  position  and  circum- 
stances of  the  bowel  render  it  capable  of  being  snared. 

The  strangidation  of  a  loop  of  intestine  by  the  simple 
noose  or  spiral,  depicted  on  page  37,  would  appear  to  be 
I'airly  common  in  the  case  of  diverticular  cords.  The  numerous 
specimens  found  in  museums,  where  these  cords  are  seen  to 
have  made  one  and  a  half  or  two  turns  round  the  involved 
bowel,  are  probably  of  this  character.  An  example  of  this 
variety  of  strangulation  in  its  simplest  form  is  depicted  in 

Fig.  14.^  In  some 
instances  the  band 
will  be  seen  to  have 
passed  twice  round 
the  bowel  at  the 
point  of  constric- 
tion.f  In  other 
specimens  one  turn 
and  a  half  is 
made.  A  reference 
to  the  drawing  taken 
Irom  Sir  Astley 
Cooper's  work  (Fig. 
9)  will  show  the 
manner  whereby  the 
gut  is  snared  in 
these  nooses,  and 
will  also  explain 
how  in  constriction 
by  a  simple  spiral 
an  appearance  is 
produced  as  of  a 
cord  passing  one 
and  a  half  or  two 
times  round  the  bowel.  ^Gvy  often  the  strangulation  by 
a  noose  is  a  little  more  complicated.  In  a  case  reported  by 
Dr.  Bristov/e,]:  the  spiral,  although  simple  in  itself,  was  yet  so 

*  Lond.  Hosp.  Museum,  No.  As,.  2. 

t  For  sptcliiiens  me  St.  Bart.'s  Hosp.  Museum,  No.  2172,  and  University 
Coll.  Museum,  No.  1167. 

\  Path.  6oc.  Trans.,  vol.  x.\i.,  p.  185. 


Fig.   14. — Strangulation  by  Meckel's  Diverticulum. 

a,  point  of  origin  of  diverticle.     Tlie  ilistal  end  is  attached  to 
the  mesentery.     The  loop  involved  measured  12  inclies. 


STRANGULATION    BY   MECKEL'S    DIVERTICULUM.     4^ 


arranged  around  the  intestinal  coils  as  to  compress  them  in 
four  diti'erent  places.  In  a  case  recorded  by  Moscati,  ^  the  di- 
verticular band  formed  a  definite  figure  of  8  loop  in  which  the 
intestinal  coi]s  were  so  involved  as  to  be  constricted  in  three 
places.  What  mechanism  is  involved  in  j^roducing  these 
extraordinary  forms  of  obstruction,  and  what  movements  of 
the  bowel  and  what  arrangement 
of  the  band  are  requisite,  must 
be  matters  of  some  speculation. 

Fig.  15  will  possibly  serve  to 
show  how  the  snaring  ligament, 
when  it  is  long,  may  present  a 
relation  to  the  bowel  which 
would  be  very  difficult  to  appre- 
ciate and  interpret.  Fkk  lo.— Diagram  to  show  a  possible 

The  relative  frequency  of   the   method  of  snaring  by  a  long  ligament. 

two     forms      of      strangulation  "*'■<? -""^>^p  ^  ^'^^-P^^-.^^^  """"s^*!^* 

already     described,     viz.     under 

the  band   and   by  the   noose  or 

knot,  is  represented  by  Leichten- 

stern,   by   the   fisfures   40   and    14   in    a 


bight  B.  The  complex  disposition  of  tlie 
band  Ciin  be  illustrated  by  assuming 
a  knuclile  of  bowel  to  pass  through  the 
snare  at  either  of  the  points  marked  C. 


figures     are     a     little     difficult 


total   of    54    cases, 
to     understand,    if 


in    connection    with    the   experience    gained    by   an 


These 
taken 

examination  of  all  the  specimens  to  be  found  in  the  various- 
museums  of  London.  These  specimens  certainly  appear 
to  show  that  strangulation  by  snaring  is  by  no  means  un- 
common, and  that  this  form  of  obstruction  does  not  bear 
to  the  constrictions  under  the  band  so  wide  a  proportion  as 
1  to  4.  If  one  could  judge  from  an  inspection  of  museum 
specimens  only,  it  would  seem  that  strangulation  under 
the  diverticular  band  is  only  about  twice  as  frequent  as  is 
the  more  complicated  method  of  obstruction.  According  to 
Leiclitenstern's  figures,  strangulation  by  the  noose  is  relatively 
raore  frequent  in  the  case  of  peritoneal  adhesions  than  it  is  in. 
the  case  of  the  congenital  band.  This  fact  also  is  in  direct 
opjjosition  to  the  conclusions  derived  from  the  niuseum 
specimens,  and  I  am  inclined  to  believe  that  obstruction  by 
snaring  is  relatively  more  frequent  when  the  diverticulum  is 
concerned  than  when  the  trouble  is  brought  about  by  the 
false  ligament.  This  latter  conclusion  is  one  that  would 
be  anticipated  if  the  greater  average  length  and  the 
greater  mobility  of  the  diverticular  ligament  be  borne  in. 
mind. 

3.  Strangulation  by  Knots   formed  by  a   Free  Diverti- 
culum.— These  remarkable  knots  and  the  methods  of  their 

*  Mem.  de  I'Acad.  de  Chirurg.,  tome  iii.,  p.  468. 


50 


MORBID    ANATOMY. 


a. 


The 


formation  have  been  very  exhaustively  studied  by  M.  Parise.''^ 
To  produce  these  knots  it  is  necessary  that  the  diverticuhini 
should  be  of  good  length,  should  be  quite  free  (save  only  for 
its  intestinal  attachment),  and  shoulcl  jDossess  an  ampulla  at 
its  extremity.  The  importance  of  the  ampulla  is  paramount, 
and  French  writers  are  in  the  habit  of  speaking  of  it  as  la 
clef  de  retranglement  Three  varieties  of  knot  may  be 
described : 

diver  tide  forms  a  ring  into  which  its  own  free 
end  projects  (Fig.  16).  A  100^3  of  intestine 
eiitsring  the  centre  of  that  ring  Avill  push  the 
clubbed  end  of  the  process  before  it,  and  so  tie 
the  knot  by  which  the  coil  becomes  obstructed. 
h.  The  diverticulum  surrounds  the  pedicle  of 
an  intestinal  loop  in  such  a  way  as  to  encircle  it 
with  a  simple  knot.  The  mode  of  formation  of 
the  noose  is  shown  in  Fig.  17.  Of  this  variety 
M.  Regnault  gave  many  years  ago  an  excellent  exanij)le. 
The  diverticulum  was  in  this  case  six  inches  in  length,  and 
by  its  means  one  and  a  half  feet  of  intestine  were  strangulated, 
c.  In  this  form  two  loops  of  the  bowel  are  involved 
(Fig.  18),  one  above,  a,  and  the  other   below,  6,  the  origin 


Fig. 


A  B  C 

Fig.  17. —One  mode  of  Strangulation  ty  the  Diverticulum.     {Begnault-Beclard). 
a,  origin  of  diverticle ;    6,  its  clubbed  extremity. 


of  the  diverticulum  d.  One  of  the  loops  enters  the  knot 
by  a  preliminary  rotation  ("  anse  rotatoire  "),  e,  the  other,  is 
noosed  by  the  diverticulum,  as  in  the  simple  knot  ("  anse 
nodale "),  c.  There  appears  to  have  been  only  one  case 
recorded  of  this  species  of  knott  The  commonest  form  of 
knot  is  undoubtedly  the  second  of  the  three  now  given. 

Fig.  19  shows  the  strangulation  of  a  coil  of  ileum  by  a 
diverticular  liga7X)ent  which  ended  in  a  rounded  mass  of  fat.  J 

*  Bull,  de  I'Acal  ds  Med.,  tome  xvi.,  p.  373. 

t  "  Observat.  d'une  novivelle  Forme  d'Etrang.  dite  par  Noeud  intestinal," 
by  Dr.  M.  Levy  ;   Gazette  Medicale,  1845,  p.  129. 
X  Royal  Coil,  of  Surg.  Museum,  No.  2695  B. 


STRANGULATION   BY   MECKEL'S    DIVEBTIGULUM.     51 


Diverticula  and  diverticular  ligaments  may  lead  to  other 
forms  of  obstruction  which  do  not,  however,  come  under  the 
present  category.  These  forms  may  be  enumerated  here  for 
the  sake  of  completeness,  and  will  be  dealt 
with  further  in  subsequent  paragraphs. 

4.  Strangulation  over  a  Diverticular 
Band. — In  this  form  a  loop  of  intestine  is 
thrown  over  a  tightly-drawn  diverticular 
band  as  a  shawl  is  thrown  over  the  arm. 
Under  certain  conditions,  an  obstruction 
follows  in  the  bowel  so  displaced.  The  oc- 
clusion is  somewhat  similar  to  that  which 
would   take   place  in  a  coil   of  thin  india-  '^^?.-  ^^^  "T,^*'^"^"!?' 

,  ,  ,  .     i   .        ,  .  ticn  by  the  Diveiti- 

rubber  tubing  it  thrown  across  a  tense  wire      cnium  by  a  double 
cord    and    allowed    to   become    dependent,     'k.^o^- 
{See  page  75,  Chap.  ITI) 

5.  Strangulation  by  Kinking. — If,  in  certain  circum- 
stances, much  traction  be  brought  to  bear  on  a  diverticular 
ligament,  the  gut,  without  undergoing  any  structural  altera- 
tion, may  become  so  acutely  bent  at  the  point  of  origin  of 
the  abnormal  band  or  process  as  to  be  occluded.  It  has 
been  shown  also  that  a  free  diverticulum,  when  of  good 
size,  and  coming  off  at  about  a  right  angle  with  the  bowel. 


Fig.  19, — Portion  of  Ileum  sh-augulated  by  a  fibrous  cord  (the  remains  of  the 
omphalo-niesenteric  duct)  which  terminated  in  a  rounded  mass  of  fat  (Royal 
Coll.  of  Surg.  Mus.,  No.  2695  B). 


52  MORBID    ANATOMY. 

may  cause  such  bending  of  the  bowel,  when  the  punch  is 
much  distended,  as  to  give  rise  to  obstruction.  This  form 
of  obstruction  is  dealt  with  in  the  next  chapter  (page  77). 

6.  The  Diverticulum  in  Association  with  Intussuscep- 
tion.— The  diverticulum  may  become  invaginated  into  itself, 
and  protruding  into  the  ileum  may  produce  or  be  associated 
with  intussusception.  A  specimen  in  Guy's  Hospital  Museum* 
shows  a  short  finger-like  diverticulum  which  had  become 
inverted,  had  projected  into  the  lumen  of  the  intestine,  and 
had  apparently  caused  an  intussusception.  Fig.  72  is  from  a 
specimen  in  the  museum  of  the  Royal  College  of  Surgeons,  f 
Here  a  diverticulum,  one  inch  and  a  half  in  length,  had 
become  so  invaginated  as  to  project  into  the  lumen  of  the 
ileum  and  produce  an  intussusception.  The  patient  was  a  boy 
aged  four  years.  The  symptoms  were  acute,  and  he  died  on 
the  fifth  day.  Mr.  Golding  Bird];  has  recorded  a  case  of  intus- 
susception of  the  ileum  through  the  lumen  of  a  Meckel's 
diverticulum,  which  was  itself  prolapsed  at  the  umbilicus, 
and  patent  at  that  spot. 

7.  Volvulus  of  the  Diverticulum.- — Mr.  Car  war  dine  §  re- 
ports a  case  of  volvulus  of  Meckel's  diverticulum  which 
caused  the  death  of  a  newly-born  child  on  the  third  day 
of  life,  an  operation  having  failed  to  give  relief  A  large 
Meckel's  diverticulum,  distended  with  meconium,  had  become 
twisted  upon  itself.  The  intestinal  end  of  the  diverticulum 
showed  some  three  turns,  and  was  thus  rendered  impervious. 
The  ileum  was  occluded  at  the  point  of  origin  of  the 
process.  The  diverticulum  formed  a  huge  sac,  and  into 
the  bowel  bej^ond  it  no  meconium  had  entered.  It  seems 
as  if  there  had  been  a  congenital  stricture  of  the  ileum, 
and  that  all  the  meconium  had  poured  into  the  diverti- 
culum, converting  it  into  a  large  receptacle  which  became 
finally  twisted  upon  itself. 

8.  Stenosis  of  the  Bowel  at  the  Point  of  Origin  of  tlie 
Diverticulum. — A  large  number  of  cases  have  been  reported 
in  Avhich  the  ileum  at  the  seat  of  origin  of  the  diverticulum 
was  narrowed.  The  degree  of  stenosis  has  been  subject  to 
much  variation.     Some  illustrative  cases  may  be  given. 

Dr.  Southeyll  reports  the  case  of  a  boy,  aged  sixteen,, 
who  died  with  symptoms  of  intestinal  obstruction  whicli 
had   lasted   for   ten   days.      The   attack   came   on  suddenly 

*  Guy's  Hosp.  Museum,  Xo.  1819  (45). 

t  Royal  Coll.  oi:  Surg.  Museum,  No.  2718  A. 

X  Clin.  Soc.  Trans.,  1896,  p.  33. 

§  Brit.  Med.  Journ.,  Dec.  4,  1897,  p.  1637. 

II  Clin.  Soc.  Trans.,  vol.  xv.,  1882,  p.  159. 


OBSTRUCTION  DUE   TO  MECKEL'S  DIVERTICULUM.  53 


slight 


(daring  perfect  health)  with  colicky  pains,  retching,  and 
purging.  The  diarrhoea  was  soon  replaced  by  absolute  con- 
stipation which  persisted  until  death.  Vomiting  came  on, 
and  on  the  sixth  day  was  stercoraceous.  It  was  always 
copious,  and  occurred  at  long  intervals.  The  pain  also  was 
intermittent  in  character.  The  autops}^  .revealed 
general  peritonitis.  A  di- 
verticulum, four  inches 
long,  passed  from  the 
ileum  to  be  attached  to 
the  anterior  abdominal 
wall  just  below  the  umbil- 
icus. Immediately  above 
the  diverticle  the  gut  was 
so  contracted  that  it  would 
only  admit  the  tip  of  the 
little  finger.  It  was  also 
deeply  ulcerated  here.  The 
two  feet  of  bowel  that  ex- 
tended between  the  abnor- 
mal process  and  the  cfecum 
were  intensely  congested. 
The  lumen  of  the  diverticle 
was  equivalent  to  that  of  a 
goosequill.  {See  Fig.  20.)^ 
It  is  assumed  that  the 
acute  symptoms  which 
caused  death  were  due  to 
strangulation  of  the  bowel 
beneath  the  diverticulum, 
which,  it  will  be  noticed, 
was  adherent.  As  no  loops 
were  found  to  be  actually 
strano-ulated,  it  is  more 
probable  that  the  narrowed 
ileum  was  occluded  by 
acute  bendinof  or  kinkino- 

due  to  traction  upon  the  diverticulum.  Dr.  Southey  reports 
another  case  (in  the  same  paper)  of  a  girl,  aged  thirteen 
and  a  half  years,  who  died  with  general  peritonitis  depend- 
ing upon  an  acute  obstruction  of  six  days'  duration.  Four 
years  previously  she  had  been  under  treatment  for  severe 
constipation.  At  the  autopsy  a  diverticulum  extended 
between  the  lower  ileum  and  the  umbilicus.  The  gut 
immediately  above  it  was  so  constricted  as  to  have  a  diameter 

*  St.  Bart.'s  Hosp.  Museum,  No,  217o. 


FtG   20. — Steuosis   of  the    Ileum  above  the 
origin  of  a  Meckel's  Diverticulum. 


54  MORBID    ANATOMY. 

of  only  half  an  inch.  No  other  cause  of  obstruction  was 
found.  Here  also  there  is  little  doubt  but  that  the  final 
acute  attack  was  clue  to  kinking,  rendered  possible  by  the 
stenosis  of  the  bowel. 

In  a  case  by  Dr.  Hare  a  diverticulum  one  inch  and 
three-quarters  in  length  was  adherent  to  the  inguinal  canal 
into  which  it  had  protruded.  The  ileum  immediately 
above  the  diverticle  was  so  narrowed  as  to  be  only  two- 
eighths  of  an  inch  in  diameter.  The  mucous  membrane  was 
here  ulcerated,  and  a  fatal  perforation  had  occurred.'^  The 
patient  had  had  symptoms  of  chronic  obstruction  in  the 
small  intestine. 

In  a  case  placed  on  record  by  M.  Carriere,  a  man, 
aged  twenty-eight,  had  peritonitis  eighteen  months  before 
his  death.  Since  this  attack  he  had  had  intermittent  grip- 
ing pains  with  constipation.  He  ultimately  succumbed  to 
an  acute  attack  of  obstruction  lasting  about  ten  days.  A 
diverticulum  arose  from  the  ileum  and  was  attached  to  the 
gut  lower  down.  Through  the  loop  thus  formed  a  coil  of 
small  intestine  had  been  strangulated  (the  cause  of  the  final 
acute  attack).  The  ileum  was  so  narrowed  at  the  point  of 
origin  of  the  diverticle  that  it  would  barely  admit  the  little 
finger,  t 

In  the  museum  of  the  Royal  College  of  Surgeons  is 
a  specimen  (No.  1361)  which  affords  another  example  of 
the  present  condition.  It  shows  a  diverticulum,  two  inches 
in  length  and  one  inch  in  width  at  its  base,  which  ends 
in  a  cord  two  and  a  half  inches  long  attached  to  the 
mesentery  one  inch  and  a  half  from  the  margin  of  the 
gut.  One  inch  above  the  origin  of  the  diverticulum  the 
gut  suddenly  becomes  narrowed  to  a  diameter  of  about 
half  an  inch,  and  remains  this  size  down  to  the  point  at 
which  the'  abnormal  process  comes  off.  Both  above  and 
below  the  narrowed  segment  the  bowel  is  normal.  Beneath 
the  arcade  formed  by  the  adherent  process  two  loops  of 
intestine  were  strangulated. 

Several  cases  similar  to  these  may  be  cited  where  the 
small  intestine  was  greatly  contracted  about  the  point  of 
attachment  of  an  isolated  "  adhesion."  j 

With  regard  to  the  nature  of  these  constrictions  in  the 
gut  it  may  be  mentioned  that  congenital  strictures  of  the 
lesser  bowel  are  met  with  most  frequently  in  the  ileum   at 

*  Path.  Soc.  Trans.,  vol.  viii.,  p.  181. 
t  Bull,  de  la  Soc.  Anat.  de  Paris,  1864,  p.  496. 

X  Mr.  Gay;  Path.  Soc.  Trans.,  vol.  iii.,  p.  101.  Mr.  Avery ;  ibid.,  vol.  iv., 
p.  156.     M.  Guiter  ;  Le  Prorjrcs  Medical,  1882,  p.  112. 


0B8T11UCTI0N  DUE   TO  MECKEL'S  DIVERTIGULlM.   55 

a  spot  corresponding  to  the  usual  origin  of  Meckel's  cliverti- 
culuui.  [This  subject  is  dealt  with  in  chapter  VIII.]  There 
is  every  reason  to  believe  that  these  congenital  strictures  are 
due  to  excessive  changes  incident  upon  the  obliteration  of 
the  vitelline  duct.  In  all  the  examples  of  complete  stricture 
there  has  been  no  trace  of  the  duct.  It  is  probable  that 
in  the  cases  now  under  consideration  the  stenosis  is  con- 
genital, and  due  to  irregular  developmental  changes.  I 
was  at  one  time  of  opinion  that  the  strictures  found  in 
these  cases  might  be  acquired,  and  due  to  the  eftects  of 
continued  traction  upon  the  gut.  I  was  struck  with  the 
fact  that  the  diverticulum  in  nearly  all  the  instances  of 
associated  stricture  was  adherent.  It  can  be  understood 
that  traction  up  3a  the  bowel  would  be  apt  to  lead  to  bend- 
ing of  it,  to  tho  production  of  occasional  obstruction,  and 
at  least  to  inte;'lerence  Avith  regular  peristaltic  movement. 
These  conditions  might  well  lead  to  ulceration  of  the  bowel, 
and  that  to  a  cicatricial  stricture.  In  the  first  of  Dr. 
Southey's  cases,  to  Avhich  allusion  has  been  made,  the  bowel 
was  found  to  be  ulcerated  at  the  seat  of  the  stricture.  Too 
much  weight,  however,  cannot  be  attached  to  this  fact,  and 
in  the  examples  I  have  been  able  to  examine  of  stricture 
associated  with  a  Meckel's  diverticuhim  the  narrowed  part 
has  shown  no  appearance  of  ulceration  nor  of  cicatricial 
contraction.  It  is  just  possible  that  in  a  few  instances 
the  stenosis  may  be  secondary  to  the  adherent  diverticulum, 
because  I  have  met  with  instances  in  wdiich  a  loop  of  small 
intestine  held  by  an  undoubted  adhesion  has  been  found 
to  be  narrowed  at  the  point  of  attachment  of  the  band.  I 
have  excluded  from  such  instances  those  examples  in  Avhich 
both  the  stricture  and  the  adhesion  were  evidently  due  to 
a  j)rimary  ulcer  of  the  intestine. 

Other  Diverticula  of  the  Intestine. — It  will  be  con- 
venient here  to  deal  with  certain  other  diverticula  which  are 
met  with  in  the  bowel,  and  which,  when  situated  in  the  ileum, 
may  possibly  be  mistaken  for  Meckel's  process.  These 
diverticula  are  of  two  kinds — (1)  congenital  and  (2)  ac- 
quired. 

1.  CoNGEXiTAL  DIVERTICULA. — A  pouch  is  Occasionally 
found  in  the  duodenum.  It  is  always  small,  is  placed  in  the 
"  second  part "  of  the  intestine  just  above  the  biliary  papilla, 
and  is  composed  of  the  normal  coats  of  the  bowel.  The 
mouth  of  the  pouch  is  Avide,  i  nd  its  depth  is,  as  a  rule,  about 
one  inch.  There  is  every  reason  to  believe  that  these  iso- 
lated pouches  which  are  so  constant  in  their  position  are  de- 
pendent upon  developmental  defects  or  aberration  associated 


56  MORBID    ANATOMY. 

with  the  hepatic  diverticulum.  It  is  interesting  to  note  that 
congenital  stricture  of  the  duodenum  occurs  at  the  same 
level.  So  far  as  is  known  these  pouches  produce  no  symp- 
toms and  have  given  rise  to  no  troubles.  In  the  Royal 
College  of  Surgeons  Museum  *  is  a  specimen  of  a  duodenal 
diverticulum  found  in  the  body  of  a  man  aged  seventy-two. 
It  had  caused  no  trouble. 

Certain  diverticula  ot  congenital  origin,  and  distinct  from 
Meckel's  diverticulum,  have  been  met  with  in  the  small 
intestine  beio^w  the  duodenum. 

Thus  Pollardt  describes  the  following  specimen  :  "  At  a 
distance  of  twenty-four  inches  from  the  pylorus  the  intestine 
bifurcates.  The  two  segments  are  similarly  supplied  with 
mesentery,  so  that  it  is  only  by  tracing  them  that  the  true 
intestine  and  the  diverticulum  can  be  distinguished.  The 
diverticulum  after  a  course  of  thirty-six  inches  reaches  the 
umbilicus  beyond  which  it  originally  terminated  as  a  large 
cul-de-sac  in  the  umbilical  cord.  The  other  segment  of  the 
intestine  terminates  at  the  ileo-csecal  valve  after  a  course 
of  sixty-three  inches."  Possibly  of  like  nature  to  this  is 
a  specimen  of  apparently  "  double  intestine,'  from  the 
Warren  Museum,  U.S.A.,  figured  in  Dennis's  "System  of 
Surgery."  J 

Buzzi  I  describes  a  diverticulum  of  the  jejunum  situated 
about  three  feet  from  the  duodenum. 

In  Dennis's  "  System  of  Surgery  "  (loc.  cit.)  is  a  drawing 
of  a  specimen  in  the  Warren  Museum  showing  a  diverticulum, 
very  much  like  a  distended  vermiform  appendix,  growing 
from  the  small  intestine  at  its  line  of  attachment  and  extend- 
ing between  the  layers  of  the  mesentery.  Some  writers  have 
described  a  JMeckel's  diverticulum  with  a  similar  relationship 
to  the  mesentery. 

Congenital  diverticula  in  the  colon  are  very  rare.  Hale 
White  describes  a  diverticulum  half  an  inch  long  and 
admitting  a  No.  10  catheter,  which  was  discovered  in 
the  colon  of  an  adult  ten  inches  from  the  ileo-csecal 
valve.  II 

Futtererll  gives  an  account  of  a  congenital  diverticulum  of 
the  sigmoid  flexure  which  formed  an  enormous  globe-shaped 
projection  from  the  bowel  wall. 

*  No.  2428  B. 

t  Path.  Soc.  Trans.,  1896,  p.  47. 

+  Vol.  iv.,  p.  295,  1896. 

^    Virchow's  Archiv. ,  1885,  vol.  c,  p.  357. 

11   Clifford  Allbutt's  "System  of  Medicine,"  vol.  iii.,  p.  973. 

IF  Archiv.  fur  Path.  Anat,,  1886,  p.  555. 


CONGENITAL    DIVERTICULA.  57 

Congenital  diverticula  of  the  rectum  have  been  reported 
by  Hulked  Ballt,  Maast  Terrier §,  and  Piatt ||. 

In  Ball's  case  there  was  some  congenital  atresia  of  the 
amis.  In  Maas'  case  the  patient  was  a  boy  of  fourteen, 
who  had  presented  some  distension  of  the  abdomen  since 
birth.  This  increased  and  caused  dyspnoea  and  disturbance 
of  the  heart.  The  boy  died  suddenly,  and  the  autopsy 
revealed  an  enormous  diverticulum  of  the  upper  part  of 
the  rectum. 

In  Terrier's  case  the  diverticulum  caused  a  constant  sense 
of  weight  in  the  rectum.  The  pouch  was  successfully 
excised. 

Piatt's  case  presents  features  of  considerable  clinical 
interest.  The  patient  was  a  little  girl  aged  nine.  The 
autopsy  showed  that  she  had  a  stricture  of  the  small  intes- 
tine, due  probably  to  the  contraction  of  a  tuberculous  ulcer. 
This  stricture  had  become  plugged  by  a  hard  faecal  mass, 
and  the  child  presented  the  symptoms  of  acute  obstruction. 
On  examination  by  the  rectum  during  life  a  soft  elastic 
tumour  was  felt  pressing  upon  the  anterior  wall  of  the 
bowel.  At  its  lower  extremity  was  an  orifice  like  an  os 
uteri,  into  which  the  finger  could  be  introduced.  This  was 
supposed  to  be  the  orifice  of  an  invaginated  piece  of  bowel, 
and  the  case  was  presumed  to  be  one  of  intussusception. 
The  autopsy  showed  that  there  was  no  invagination  of  any 
part  of  the  gut,  and  the  tumour  proved  to  be  a  diverticulum 
of  the  rectum,  into  the  orifice  of  which  the  finger  had  been 
introduced  in  the  rectal  examination. 

2.  Acquired  Diverticula. — The  greater  number  are 
merely  hernial  protrusions  of  the  mucous  membrane  of  the 
bowel  through  the  muscular  coat,  and  hence  the  common 
name  "  distension  diverticula."  In  structure  they  are  com- 
posed, in  most  instances,  simply  of  mucous  membrane  and 
peritoneum.  They  present  in  their  walls  few,  if  any,  muscular 
fibres.  The  lining  mucous  membrane  in  the  smaller  pouches 
is  quite  normal,  but  in  the  larger  diverticula  that  membrane 
becomes  atrophied,  and  its  glandular  structures  tend  to 
disappear.  They  may  be  met  with  in  any  part  of  the  bowel, 
but  are  more  often  found  in  the  large  than  in  the  small 
intestine.  They  have  been  seen  in  the  jejunum,  and  are  en- 
countered with  still  greater  frequency  in  the  ileum.    (Fig.  21.) 

*  Trans.  Path.  Soc,  1873,  p.  87. 

t  "Diseases  of  the  Rectum,"  1887,  p.,  42. 

1^  Annual  of  the  Universal  Med.  Sciences,  1889,  vol.  iii. 

§  Mevue  de  Clurnryif.,  1889,  p.  929. 

II  Lancet,  vol.  i.,  1873,  p.  42. 


58 


MOB  BID    ANATOMY. 


They   may  appear  in   any  part  of  the 


I'iG.  21. — Multiple  Sacrali  or  Diverticula  of   the 
Small  Intestine. 

The  protrusions  are  along  the  mesenteric  border  of  the 
bowel,  and  are  composed  only  of  mucous  membrane 
(Royal  Coll.  of  Surg.  Mus.,  No.  2455  C). 


colon,  but  are  most 
common  in  the 
sigmoid  flexure  and 
rectum. 

In  the  matter  of 
Dumbers  they  show 
the  greatest  variety, 
and  are  far  more 
frequently  multiple 
than  single.  The 
chief  examples  of 
multiple  diverti- 
cula are  met  with 
in  the  large  intes- 
tine.  Alibert 
counted  two  hun- 
dred in  one  colon. 
In  the  museum  of 
St.  Thomas's  Hos- 
pital is  a  sigmoid 
flexure,  the  whole 
surface  of  which  is 
studded  with  a 
multitude  of  little 
hernial  pouches, 
varying  in  size  from 
a  pin's  head  to  a 
marble.  Hamilton^ 
describes  numerous 
pouches  of  larger 
size  in  the  same 
section  of  the 
bowel.  In  another 
case  reported  by 
Hale  Whitet  the 
descending  colon, 
sigmoid  flexure  and 
upper  part  of  the 
rectum  presented 
numerous  diverti- 
cula about  one- 
third    of    an    inch 

diameter.     The 

were  about 

half     an    inch     in 


in 
largest 


*  New  York  Med.  Rec,  1888,  p.  721.  f  Trans.  Path.  See,  1885,  p  215. 


\        AGQUIIiED    DIVERTICULA.  59 

\ 

depth.  Fig.  22,  from  Sir  Astley  Cooper's  work  on  liernia, 
shows  a  ieiunum,  alonsr  the  mesenteric  border  of  which  dis- 
tension  diverticula  are  crowded  ahnost  as  closely  as  they 
can  lie. 

The  chief  examples  of  single  pouches  are  met  with  in 
the  lesser  bowel.  Thus  Dr.  Bristowe  has  reported  an  instance 
of  a  single  diverticulum  no  larger  than  a  horse-bean  situated 
in  the  ileum  just  above  the  ileo-c;;ecal  valve.^  In  other 
cases  only  two  pouches  were  found  in  the  small  intestine, 
as  in  an  instance  noted  by  Dr.  Hilton  Fagge,  where  the 
abnormal  sacs  were  both  in  the  jejunum.f 

In  size,  the  false  diverticulum  may  also  show  any  dimen- 
sions between  that  of  a  pin's  head  and  that  of  a  large 
apple.  The  majority  of  those  in  the  colon  are  about  the 
size  of  a  pea.  In  shape  they  are  usually  globular,  especially 
when  small. J  When  of  larger  size  they  may  become 
lobulated,  as  is  the  case  with  one  of  the  diverticula  shown 
in  Fig.  23.  §  It  is  extremely  rare  for  them  to  assume  the 
conical  shape  or  finger-like  outline  so  commonly  met  with 
in  Meckel's  diverticula.  They  may  be  narrower  at  the 
attached  extremity  than  at  the  fundus, 
and  are  apt,  Avhen  of  good  size,  to  assume 
a  polypoid  outline.  Fig.  24  shows  a 
pedunculated  diverticulum  Avhich  con- 
tained a  foreign  body. 

As  regards  the  relation  of  these  hernial 
pouches  to  the  intestinal  wall,  it  will  be 
found  that  in  the  lesser  bowel  they  invari-  ^^^-  -2- 

ably  appear  along  the  mesenteric  border 
of  the  gut,  and  force  their  way  as  they  enlarge  between  the 
two  layers  of  the  mesentery.  In  the  colon  they  are  usually 
met  with  on  those  parts  of  the  intestine  to  which  the  appen- 
dices epiploicfe  are  attached,  and  into  the  substance  of  these 
appendages  the  pouch  will,  as  a  rule,  be  found  to  have 
projected.  This  relation  of  the  diverticulum  to  the  appen- 
dices Avas  admirably  shown  in  the  case  reported  by  Dr. 
Bristowe. 

These  multiple  pouches  may  be  regarded  as  hernia  of 
the  mucous  membrane  through  the  muscular  coat.  They 
occur,  with  but  few  exceptions,  in  elderly  people ;  and  those 
of  the  colon  are  usually  associated  with  a  history  of  chronic 
constipation.      In    the    small   intestine   also   the   diverticula 

*  Path.  Soc.  Trans.,  vol.  vi.,  p.  191. 

t  Ibid.,  vol.  xxvii.,  p.  147. 

X  Giij^'s  Hosp.  Museum,  No.  1,819  (69). 

5  Royal  Coll.  of  Surg-eons  Museum,  No.  1177. 


€0 


MORBID    ANATOMY. 


are  often  attended  by  conditions  bringing  about  distension 
of  the  bowel.  {See  page  20  and  Fig.  2.)  In  Sir  Astley 
Cooper's  case  the  pouches  were  in  the  jejunum,  while  in  the 


Fig.  23  — Distension  Diverticula. 


ileum  was  an  obstruction  that  had,  no  doubt,  encouraged  a 
long-continued  distension  of  the  gut.  In  several  other  in- 
stances the  protrusions  were  met  with  in  patients  who  had 
suffered  from  hernia,  the  diverticula  being  situated  in  a  part 
of  the  bowel  above  that  involved  in  the  rupture.  Of  the 
exact  pathology  of  these  little  pouches  it  must  be  confessed 


ACQUIRED    DIVER  TIG  VIA. 


61 


that  very  little  is  known.  If  they  be  clue  to  distension  it 
is  difficult  to  understand  why  they  are  so  uncommon  even 
in  cases  of  chronic  intestinal  obstruction. 

In  the  Royal  College  of  Surgeons  Museum"^  is  a  speci- 
men of  the  colon  containing  pouches,  fi-om  these  come  off 
certain  secondary  diverticula,  which  contain  concretions 
composed  of  eighty  parts  of 
cholesterine  and  twenty  parts 
of  carbonate  of  lime. 

These  pouches,  and  espe- 
cially those  of  the  colon,  are 
apt  to  lodge  little  fsecal 
masses  and  foreign  matters 
of  various  kinds.  Inflam- 
mation of  the  pouch  may  be 
induced  by  such  lodgment, 
and  peritonitis  from  perfora- 
tion result,  just  as  occurs  in 
the  appendix  vermiformis. 
{See  Fig.  24.)  Attention  has 
already  been  drawn  to  the 
fact  that  the  colic  diverticula 
are  apt  to  project  into  appen- 
dices epiploicse ;  and  it  is 
quite  probable  that  in  those 
cases  where  such  an  appendix 
has  caused  an  isolated  ad- 
hesion a  pouch  might  have 
formed  in  the  appendage, 
have  lodged  a  foreign  sub- 
stance of  some  kind,  and 
have  been,  in  consequence, 
the  seat  of  a  limited  peri- 
tonitis. Thus,  Mr.  Hulke  records  a  case  where  an  epiploic 
appendage  was  adherent  to  the  pelvic  peritoneum  near  the 
right  sciatic  notch.  Beneath  the  arcade  so  formed  a  loop 
of  bowel  had  been  strangulated.  The  appendix  w^as  on  the 
sigmoid  flexure,  which  extended  in  an  angular  loop  across 
the  pelvis.t  In  a  specimen  in  the  Royal  College  of  Surgeons 
Museum  J  it  will  be  seen  that  an  appendix  has  become  ad- 
herent to  the  omentum  in  such  a  way  as  to  cause  stenosis  of 
the  part  of  the  colon  from  which  it  arose.     (Fig.  25.)     In  this 


Fig    24. — Diverticulum  of  the  Lower 
Jejunum. 

The  process  is  perforated,  and  contains  a  pea 
(Royal  Coll.  of  Surg.  Mus.,  2452). 


*  No.  2455  E. 

t  Medical  Times  and  Gazette,  toI.  ii.,  1872,  p.  482. 

X  Koyal  Coll,  of  Surgeocs  Museum,  Xo.  2693. 


62  MORBID   ANATOMY. 

case  the  comparatively  large  size  of  the  involved  appendix 
is  conspicuous.     {See  also  page  64.) 

I  have  found  cases  on  record  where  a  diverticulum  in 
the  sigmoid  flexure  communicated  with  the  interior  of  the 
bladder  by  an  ulcerated  opening.  Here  also  it  is  probable 
that  inflammation  was  excited  in  the  pouch  by  the  lodgment 
of  a  fsecal  mass ;  by  the  peritonitis  set  up  the  process  became 
adherent  to  the  bladder,  and  by  the  extension  of  ulceration 
from  the  diverticulum  the  bladder  was  perforated.^  One  of 
the  patients  passed  fsecal  matter  by  the  urethra,  while 
another t  seems  to  have  been  more  troubled  by  the  escape 
of  urine  into  the  rectum.  It  is  just  possible  that  in  those 
somewhat  numerous  cases  in  Avhich  air  and  faeces  are  found 
to  pass  from  the  urethra  the  communication  between  the 
colon  and  the  bladder  is  effected  through  a  distension 
diverticulum  of  the  bowel. 

Mr.  Harrison  Cripps,  in  dealing  with  examples  of  this 
communication,  has  shown  that  in  the  majority  of  instances 
the  fistula  is  not  due  to  malignant  disease,  but  has  followed 
upon  simple  inflammatory  changes.! 

4.  Strangulation  by  Normal  Structures  Abnormally 
Attached. 

A.  The  venniforin  appendix  may  become  adherent  to 
some  point  on  the  neighbouring  peritoneum,  and  so  form 
a  band  or  arch  beneath  which  a  loop  of  intestine  may 
be  strangulated.  The  process  is  very  commonly  adherent 
to  the  mesentery  of  the  lower  ileum.§  Less  frequently  it 
is  adherent  to  the  ileum  itself, ||  or  to  the  csecum,  or  to 
the  peritoneum  about  the  right  iliac  fossa  and  margin  of 
the  pelvis.  In  one  instance,  reported  by  Sir  Risdon  Bennett, 
the  appendix  was  adherent  to  an  enlarged  ovary  on  the  right 
side,  and  beneath  the  cord  so  formed  a  loop  of  the  ileum  and 
a  part  of  the  ascending  colon  were  constricted^ 

I  have  met  with  a  case  in  which  the  appendix  was 
adherent  to  the  bladder,  and  beneath  it  was  a  coil  of  com- 
pressed ileum. 

In  some  rare  cases  the  appendix  has  been  described  as 
wound  in  the  form  of  a  close  spiral,  or  of  a  ring  into  which  a 
loop  of  intestine  had  entered  and  had  become  strangulated. 
In  other  instances,  equally  uncommon,  the  appendix  is  said 

*  Path,  Soc.  Trans.,  vol.  x.,  p.  131. 

t  T^iid.,  vol.  X.,  p.  208. 

+  "  The  Passage  of  Air  and  Faeces  from  the  Urethra."     Lond.,  1888. 

§  Guy  s  Hosp.  Museum,  No.  2508  (50). 

II  See  a  good  case  by  Mr.  Gay  ;  Path.  Soc.  Trans.,  vol.  iii.,  p.  101. 

11  Path.  Soc.  Trans.,  vol.  iv.,  p.  146.     The  specimen  is  now  in  St.  Thomas's 
Hosp.  Museum,  No.  R  17. 


STRANGULATION   BY  ATTACHED    STRUCTURES.      63 

to  have  tied  itself  into  an  actual  knot  o±  a  character  similar 
to  those  sometimes  formed  by  the  true  diverticulum.  By 
such  a  knot  the  bowel  has  been  constricted. 

It  must  be  confessed  that  this  last-mentioned  form  of 
obstruction  is  a  little  difficult  to  credit.  The  average  length 
of  the  appendix  is  only  three  and  a  half  inches.  It  is 
often  four  or  five  inches,  and  has  been  found  to  reach  and 
even  exceed  the  length  of  nine  inches. 

B.  In  several  instances  the  Fallopian  tube  has  become 
adherent  to  some  part  of  the  neighbouring  peritoneum,  to 
that,  for  example,  lining  one  of  the  iliac  fossas,  and  beneath 
the  arcade  so  formed  a  portion  of  the  small  intestine  has  been 
strangulated."^ 

C.  A  few  cases  are  reported  where  a  loop  of  bowel  has 
been  strangulated  beneath  a  band  formed  by  a  fixed  portion 
of  the  inesentery.  In  these  examples  some  coils  of  the  small 
mtestine  become  fixed  at  a  distant  spot.  They  may  be 
involved  in  a  large  irreducible  hernia,  or  may  have  hung 
down  into  the  pelvis,  and  acquired  adhesions  when  in  that 
position.  In  such  circumstances  the  corresponding  part 
of  the  mesentery  may  become  tightly  stretched  across  the 
posterior  wall  of  the  abdomen  or  the  pelvic  brim,  and  a  bridge 
be  thus  formed  beneath  which  some  of  the  lesser  bowel 
may  become  strangulated. t  Duchaussoy  appears  to  be  of 
opinion  that,  wdien  a  large  coil  of  the  ileum  simply  hangs  down 
into  the  pelvis,  the  arch  then  formed  by  the  mesentery  may 
be  of  such  a  character  that  the  intestine  can  be  obstructed 
beneath  it.  Such  a  circumstance,  however,  must  be  ex- 
tremely exceptional  in  the  absence  of  any  adhesions  holding 
the  dependent  bowel  in  place.  In  cases  of  acute  ob- 
struction it  is  common  enough  to  find  all  the  coils  of 
small  intestine  below  the  point  of  strangulation  hanging 
in  a  bunch  empty  and  collapsed  into  the  pelvis.  If  we 
except  these  cases,  however,  there  must  be  very  few  con- 
ditions met  with  where  large  coils  of  the  bowel  hang  listlessly 
in  the  pelvis,  and  so  form,  by  means  of  the  mesentery  a 
band  sufficiently  long  abiding  to  allow  gut  to  be  compressed 
beneath  it.  When  such  dependent  coils  are  fixed  or  ad- 
herent the  mechanism  of  the  obstruction  is  quite  intelligible. 

In  a  case  of  congenital  malposition  of  the  colon  reported 
by  Dr.  Florence  Boyd  (page  240)  it  would  appear  that  some 

*  For  cases  see  Bull.  Soc.  Anat.  de  Paris,  1841,  p.  209,  by  M.  Gaubric ;  and 
Archiv.  Gen.  de  Med.,  1829,  by  M.  Rostun. 

t  See  case  by  Dr.  Hilton  Fagge  (Guy's  Hosp.  Reports,  vol.  xiv.),  wbere  the 
ileum  was  adherent  to  a  tumour  formed  by  an  extra-uterine  foetation,  while 
beneath  its  tensely  drawn  mesentery  some  jejunum  was  strangulated. 


fA  MORBID    ANATOMY. 

coils  of  small  intestine  were  compressed  beneath  the  stretched 
mesentery,  there  being  at  the  same  time  an  absence  of  ad- 
hesions. 

D.  To  the  bands  formed  by  adherent  appendices  epiploicae 
allusion  has  already  been  made.     {See  page  61.) 

Dr.  Perry^  reports  two  interesting  examples  of  this  con- 
dition. Both  patients  were  women  and  both  were  aged  forty- 
eight.  In  both  there  were  symptoms  of  acute  obstruction  and 
in  both  laparotomy  was  performed.  The  patients  were  in  a 
very  exhausted  condition  at  the  tune  of  the  operation  and 
death  followed  in  each  instance  in  some  few  hours. 

In  one  case  a  loop  of  ileum,  measuring  four  to  five  inches, 
had  slipped  between  two  adjacent  appendices  epiploicoe  which 
were  united  by  fine  thin  adhesions  at  their  tips.  The  pair  of 
appendices  were  situated  ten  inches  from  the  lower  end  of  the 
rectum.  In  the  second  example  thirty-one  inches  of  the 
ileum  had  been  snared.  The  pair  of  appendices  which  had 
become  adherent  to  one  another  were  attached  to  the  bowel 
twelve  inches  from  the  lower  end  of  the  rectum.  In  Mr. 
Holmes's  case  described  on  page  68,  it  is  just  possible  that 
the  strangulating  ring  found  on  the  sigmoid  flexure  was 
formed  out  of  two  adherent  appendices  of  the  type  described 
by  Dr.  Perr}^ 

In  the  museum  of  the  Royal  College  of  Surgeonsf  is  a 
specimen  taken  from  a  girl  of  fifteen,  the  subject  of  tuber- 
culous peritonitis,  in  which  a  coil  of  ileum  thirty  inches  in 
length  was  strangulated  beneath  a  "  band."  The  band  was 
formed  by  an  appendix  epiploica  which  arose  from  the  sigmoid 
flexure  and  attached  itself  to  the  mesentery. 

Fig.  25J  shows  constriction  of  the  bowel  by  one  of  the 
appendices  epiploic*  which  is  adherent  to  the  omentum.  The 
specimen  is  alluded  to  on  page  61. 

Mr.  Bidwell§  records  a  case  of  acute  intestinal  obstruction 
in  a  woman,  aged  twenty-eight,  which  was  due  to  the  strangu- 
lation of  a  loop  of  ileum  beneath  a  band  formed  by  an  adherent 
appendix  epiploica  arising  from  the  sigmoid  flexure.  The 
appendix  was  attached  to  the  anterior  abdominal  parietes  and 
the  snaring  of  the  ileum  was  rendered  possible  by  the  fact  that 
both  ileum  and  sigmoid  flexure  were  in  part  adherent  to  the 
abdominal  wall.  These  adhesions  had  followed  upon  an 
ovariotomy  performed  five  months  previously.  The  obstruc- 
tion was  removed  by  operation. 

*  Path.  Soc.  Trans.,  1889,  p.  93. 

t  No.  2691  A. 

X  Eoyal  Coll.  of  Surgeons  Museum,  No.  2693. 

§  Brit.  Med.  Journ.,  May  8,  1897,  p.  1151. 


STJiANGULATJUN    THROlJQll    ^LIT^. 


65 


E.  Dr.  Hilton  Fagge  has  recorded  the  case  of  a  woman, 
aged  seventy-four,  who  died  with  s^yniptoms  of  acute  intestinal 
obstruction  that  had  lasted  for  six  days.  The  autops}^  revealed 
a  portion  of  the  ileum  strangulated  by  the  pedicle  of  a  lai^ge 
ovarian  cyst.  On  moving  the  tumour  a  little  the  obstructed 
bowel  was  easily  reduced.^ 

5.  Strangulation  through  Slits  and  Apertures, 


Fig.  2.5. — Portion  of  Colon  constrictea  by  one  of  thfi  appendices  epiploic;e  (a) 
which  has  become  adherent  to  the  omentum,  which  is  itself  attached  to  the 
bowel  by  moderate  adhesions.     {Boijal  Coll.  of  Siin/.  Miis..  No.  2693.) 


A.  Slits  and  Apertches  ix  the  Mesenteuy. — Through 
holes  formed  in  this  membrane  portions  of  intestine  have 
frequently  been  strangulated.  The  holes  are  usually  slit-like, 
and  are  most  common  in  the  mesentery  of  the  lower  ileum. 
In  other  parts  they  are  rare.  In  many  cases  these  slits  can  be 
more  or  less  distinctly  traced  to  an  injury,  aiid  several 
specimens  in  the  museums  of  London  show  that  a  limited 
rent  of  the  mesentery  may  be  the  only  visible  lesion  after 
violence  applied  to  the  abdomen.  As  an  example  of  this 
form  of  obstruction  may  be  mentioned  a  case  recorded  by 
■*■     A    man    died    with    symptoms  of  acute 


*  Guv's  Hospital  Eeports,  vol.  xiv. 

t  Trans.  Path,  and  Clin.  Soc,  Glasgow,  1893  p.  78. 


66  MOBBID    ANATOMY. 

intestinal  obstruction.  A  year  or  two  previous  to  his  death 
he  had  received  a  severe  kick  in  the  abdomen  which  was 
followed  by  much  abdominal  pain  and  distension  attended 
with  vomiting.  The  "post-mortem  showed  that  "  the  mesentery 
had  been  torn  away  at  one  point  from  its  attachment  to  the 
bowel,  and  through  a  round  hole  thus  produced  a  loop  of  gut 
had  passed,  been  strangulated  and  rendered  gangrenous." 

In  this  case  the  rent  was  close  to  the  bowel.  In  a  case 
recorded  by  Mr.  Maylard'^  the  rent  was  close  to  the  spine. 

The  patient  in  this  latter  example  was  a  boy  of  twelve.  He 
died  of  acute  intestinal  obstruction  which  had  existed  for  five 
days,  although  for  the  first  three  days  the  symptoms  amounted 
to  little  more  than  colic.  The  boy  did  not  survive  a  laparotomy 
carried  out  for  his  relief.  The  operation  showed  that  "  a  long 
loop  of  ileum — about  four  feet — at  a  distance  of  eight  inches 
from  the  ileo-csecal  valve  had  passed  through  an  aperture  in 
the  mesentery  close  to  its  spinal  attachment.  The  opening, 
which  appeared  small  enough  to  admit  onl}^  the  tip  of  the 
little  finger,  was  enlarged  and  the  bowel  withdrawn.  The 
bowel  was  completely  gangrenous  and  had,  therefore,  to  be 
removed."  Three  years  previously  the  boy  had  been  ridden 
over  by  a  cart,  the  wheel  passing  obliquely  across  the  thorax 
and  abdomen.  There  was  pain  in  the  abdomen,  and  the  child 
was  kept  in  bed  for  seven  days.  From  the  time  of  this 
accident  until  the  advent  of  the  fatal  ilhiess  he  had  been 
quite  well. 

In  other  examples  of  this  variety  of  obstruction  there 
is  practically  no  doubt  but  that  the  abnormal  aperture  is 
congenital.  The  edges  in  such  instances  are  smooth,  rounded, 
and  regular;  there  is  no  history  of  injury  and  no  trace  of 
any  previous  peritonitis.  The  hole  is  found  in  the  mesentery 
of  the  terminal  pait  of  the  ileum,  and  is  close  to  the  bowel. 
I  have  described  the  condition  leading  to  these  congenital 
holes  in  my  Hunterian  Lectures  on  the  Anatomy  of  the 
Intestinal  Canal  and  Peritoneum.f 

The  hole  is  generally  circumscribed  by  an  anastomosis 
between  the  ileo-colic  branch  of  the  superior  mesenteric 
artery  and  the  last  of  the  intestinal  arteries. 

A  common  situation  for  the  hole  is  shown  at  a  in  Fig.  26. 
I  have  frequently  found  this  particular  spot  in  the  mesentery 
of  the  fcetus  marked  by  an  area  of  peritoneum  which  is 
entirely  devoid  of  fat,  of  glands,  and  of  blood-vessels. 

In  the  fcetus  at  full  term,  and  in  children  before  pubert}^, 
his  area  is  usually  about  the  size  of  a  shilling  piece.     The 

*  The  Surgery  of  the  Alimentary  Canal,  Lond.,  1896,  p.  3.52. 
t  London,  1885,  p.  28. 


STRANGULATION    THROUGH   SLITS.  67 

margins  of  the  district  are  marked  by  the  arteries  named, 
and  are  occasionally  rendered  more  pronounced  by  some 
opacity  of  the  membrane. 

In  one  instance  of  strangulation  through  a  hole  in 
the  mesentery  the  upper  margin  of  the  aperture  was 
marked  by  a  dense  and  distinct  band,  which  contained  in 
its  substance  a  large  branch  of  the  superior  mesenteric 
artery."^ 

It  is  easy  to  understand  that  a  little  atrophy  of  the  well- 
defined  and  transparent  area  of  peritoneum  just  described 
would  lead  at  once  to  the  formation  of  a  hole. 

In  the  body  of  a  man  aged  fifty-two  I  found  this 
particular  area  in  the  mesentery  very  pronounced.  It 
formed  a  patch  of  oval  outline  measuring  one  inch  and 
three-quarters  by  one  inch  and  a  quarter.  It  was  entirely 
devoid  of  visible  vessels,  of  glands,  and  of  fat;  while  the 
adjacent  mesentery  Avas  quite  opaque  from  adipose  tissue.  The 
margm  of  the  space 
was  markedly  opaqne,  ^ 
thickened,  and  abrupt,  ^J|  J 
and  was  skirted  on  the 
side  nearest  the  ctecum 
by  one  of  the  terminal 
branches  of  the  su- 
perior mesenteric 
artery.       The      serous 

m  e  m  b  r  a  n  e  W  h  i  C  h  Fig.  26.— a,  site  of  congenital  hole  iu  the 
formed    this    area    AVas  meseutry ;    b,  pouch  in  the  peritoneum. 

very    thin    and    clear, 

and  so  atrophied  that  it  was  cribriform,  being  pierced_  b}^ 
about  twenty  holes.  It  Avas  evident  that  but  a  slight 
degree  of  force  Avould  be  required  to  drive  a  knuckle  of 
bowel  through  this  Avasted  membrane  and  so  produce  a 
strangulation  through  a  "  mesenteric  hole." 

In  one  specimen  Avhich  came  to  my  notice — in  a  male 
foetus  at  full  term— this  peculiar  oasis  in  the  mesentery  Avas 
Avell  defined,  and  the  last  intestinal  artery  had  produced  a 
fold  on  the  ca^cal  margin  of  the  patch  (p..  Fig.  26).  By 
this  means  a  pocket  Avas  formed  Avhich  could  Avith  little 
inducement  haA-e  lodged  a  knuckle  of  intestine. 

Dr.  Coats  t  has  alluded  to  an  instance  of  strangulation 
through  a  hole  in  the  mesentery,  in  Avhich  it  Avould  appear 
that  the  aperture  Avas  of  congenital  origin.  Another  ex- 
ample, in    a   girl    of  sixteen,  in   Avhich    the    hole  measured 

*  Contrib.  ti  I'Etude  de  rOccludon  Intest.,  par  U.  Lc  Moyne.     Paris,  1878. 
t  Trans.  Path,  and  Clin.  Soc,  Glasgow,  1S93,  p.  57. 


68  MOBBID    ANATOMY. 

two  inches  by  two  and  a  half  inches,  is  recorded  in  the 
Lancet  for  October  30th,  1897   (page  1111). 

In  reviewing  the  whole  series  of  cases  of  strangulation 
through  mesenteric  holes,  one  notices  that  in  most  cases 
the  amount  of  bowel  involved  was  considerable.  In  one 
case  it  was  of  sufficient  length  to  become  twisted  upon 
itself  and  form  a  volvulus.^ 

In  size  the  mesenteric  hole  or  slit  shows  great  varia- 
tion. It  may  be  no  larger  than  a  sixpenny  piece,t  or 
it  may  be  extensive  enough  to  admit  lour  fingers. J  In 
the  last-mentioned  instance  the  portion  of  bowel  involved 
was  the  sigmoid  flexure,  and  so  far  as  I  can  ascertain 
this  is  the  only  case  on  record  where  colon  has  found  its 
way  into  the  slit.  Mr.  Partridge  has  recorded  a  case,  which 
is  probably  unique,  of  strangulation  of  a  knuckle  of  ileum 
through  an  aperture  in  the  mesentery  of  the  vermiform 
appendix.  § 

In  a  few  instances  the  strangulation  has  occurred  through 
slits  in  the  transverse  and  descending  mesocolon. 

B.  Slits  and  Apertures  in  the  Omentum. — An  example 
of  this  form  of  obstruction  is  shown  in  Fig.  27. 1|  These  slits 
may  be  clue  to  congenital  defect,  but  in  many  instances 
they  can  be  distinctly  traced  to  an  injury.  M.  Le  Fort 
reports  the  case  of  a  young  man  who  developed  symptoms  of 
intestinal  obstruction  some  little  while  after  having  received 
a  kick  on  the  abdomen  from  a  horse.  The  autopsy  showed 
two  hernise  of  portions  of  the  small  intestine  through  two 
slits  in  the  great  omentum.^  In  speaking  of  omental  bands 
allusion  has  already  been  made  to  the  circumstance  that,  as 
a  result  of  violence,  a  mass  of  intestines  may  protrude 
through  an  immense  rent  in  the  omentum,  and  the  two 
divisions  of  the  membrane  thus  formed  may  develop  into 
omental  bands. 

C.  Less  Common  Forms  of  Slit. — Mr.  Holmes  has  placed 
on  record  a  remarkable  case,  where  a  loop  of  the  lower 
ileum  was  strangulated  through  a  hole  apparently  formed 
in  an  appendix  epiploica.  The  appendix  in  question  was 
attached  to  the  sigmoid  flexure,  and  formed  a  fatty  flbrous 
ring    through    which    the    loop    had    passed.      There    were 

*  Brit.  Med.  Joiirn.,  April  24,  1897,  p.  1022. 

t  Br.  Leared ;  Path.  Soc.  Trans.,  vol.  xiv.,  p.  156. 

+  M.  Trelat;  B^ai.  et  Mem.  de  la  Soc.  de  Chir.  de  Pari-',  tome  vi.,  1880, 
p.  o94. 

§   Path.  Sue.  Trans.,  vol.  xii.,  p.  liO. 

II  University  Coll.  Museum,  No.  1161.  Sea  also  specimen  in  St.  Bart.'s 
Hosp.  Museum,  No.  2177. 

If  Bull,  et  Mem.  do  In  Soe.  de  Chir.  de  Paris,  tome  v.,  1869,  p.  6!35. 


STBAXaULATlUN    THROUGH   SLITS. 


69 


several  large  and  broad  appendices  upon  the  same  segment 
of  the  colon,  some  of  which  were  perforated  near  their 
bases,  as  if  they  also  were  capable  of  developing  into  rings. '^ 
It  may  be  that  the  appearance  of  a  ring  had  been  brought 
about  by  two  adjacent  appendices  becoming  adherent  at 
their  extremities  (page  64). 

Dr.  Quain  describes   an    autopsy  where    forty   inches    of 
the   ileum    were   foimd    to   have    passed   through   a   slit   in 


Fig.  27. — Strangulation  of  small  Intestine  through  a  hole  in  the  Great 
Omentum. 


the  broad  ligament  of  the  uterus.  In  this  case,  however, 
the  gut  Avas  also  held  down  by  a  band  of  old  adhesions. f 

Barth  reports  a  case  of  strangulation  of  the  intestine 
in  a  slit  in  the  suspensory  ligament  of  the  liver.  J 

In  by  no  means  a  few  instances  a  coil  of  intestine 
has  been  contracted  by  passing  through  a  slit  formed  in  a 
broad  membranous  adhesion.  In  other  cases  the  bowel  has 
protruded  between  two  cord-like  adhesions  placed  close  to- 
gether and  parallel  with  one  another.  Mr.  Hutchinson 
mentions  an  instance  where  the  slit  was  formed  between 
a  false  ligament  and  the  edge  of  the  broad  ligament  of  the 
uterus,  by  the  side  of  which  the  adhesion  ran.§ 

*  Path.  Soc.  Trans.,  vol.  xii.,  p.  3. 
t  Path.  Soc.  Trans.,  vol.  xii.,  p.  103. 
X  Schmidt's  Jahrh.,  h.  96,  s.  207. 
II   Med.  Times  and  Ga~'tte,  1S5S. 


70  MORBID    ANATOMY. 

I  have  operated  upon  a  case  in  which  repeated  attacks 
of  intestinal  obstruction  were  due  to  the  snaring  of  a  loop 
of  small  intestine  through  a  slit  in  the  sustentaculum  lienis. 
That  fold  of  peritoneuiu  was  in  this  instance  represented 
by  two  substantial  parallel  cords.'^ 

In  some  cases  rings  and  slits  have  been  formed  between 
intestinal  loops  which  have  become  matted  together,  and 
through  these  apertures  a  non-adherent  coil  has  passed 
and  become  constricted.  In  one  case,  briefly  mentioned  by 
Sir  Astley  Cooper,  it  was  found  that  "  two  folds  of  intestine 
had  adhered  at  one  point  only  (as  may  be  represented  by 
bringing  the  points  of  the  thumb  and  finger  in  contact) ; 
through  the  noose  thus  formed  another  fold  of  intestine 
was  passed  and  had  become  strangulated."  f  The  occasional 
gaps  and  slits  which  may  be  formed  between  adherent 
intestines,  and  the  viscus  or  parietes  to  which  they  are 
attached,  may  serve  as  holes  through  which  a  coil  of  bowel 
may  pass  and  be  constricted. 

The  Portion  of  Intestine  Involved  and  the  Mechanism 
of  the  Obstruction. — In  the  form  of  intestinal  obstruction 
now  under  consideration,  although  many  very  different 
methods  are  concerned  in  the  production  of  that  obstruc- 
tion, tJte  part  of  the  alimentary  tube  involved  is,  with  scarcely 
an  exception,  the  same,  viz.  the  small  intestine. 

A  case  has  already  been  incidentally  alluded  to  where 
a  part  of  the  ascending  colon  was  found  compressed  beneath 
an  adherent  vermiform  appendix  (page  62),  and  another  where 
a  loop  of  the  sigmoid  flexure  was  strangulated  through  a 
rent  in  the  mesentery  (page  68).  Instances  may  be  given 
where  a  part  of  the  colon  has  been  obstructed  beneath  a 
tightly  drawn  mesentery  (Duchaussoy),  together  with  a  few 
other  observations  of  the  same  character.  So  rare,  however, 
is  it  for  any  part  of  the  colon  to  be  involved  in  the  present 
variety  of  intestinal  obstruction  that,  so  far  as  the  general 
bearings  of  the  whole  subject  are  concerned,  the  few  reported 
cases  may  be  regarded  almost  as  pathological  curiosities. 
If  it  be  borne  in  mind  that  the  hernia-like  strangulation 
of  the  bowel  requires  that  the  gut  to  be  involved  should 
be  quite  free  and  movable,  and  that  it  should  be  capable 
also  of  readily  forming  a  knuckle  or  loop,  it  will  be  seen 
that  no  part  of  the  normal  colon — if  we  except,  perhaps,  the 
sigmoid  flexure — has  a  disposition  that  will  allow  it  to  share 
readily  in  this  form  of  obstruction. 

In  the  great  majority  of  all  cases  the  segment  of  small 

*  Brit.  Med.  Joarii.,  April  20,  1895,  p.  864. 
t  Abdominal  Hernia,  chap.  xxxv. 


MECHANISM    OF    OBSTRUCTION.  71 

intestine  involved  is  the  lower  part  of  the  ileum.  In  a  fair 
number  of  instances  the  middle  and  upper  portions  of  the 
ileum  have  been  involved,  but  the  examples  of  strangulation 
of  the  jejunum  by  the  methods  now  under  consideration 
are  comparatively  rare.  Indeed,  it  may  be  said  that,  as 
one  follows  the  small  gut  from  the  C£ecum  to  the  pylorus, 
every  foot  of  the  distance  renders  the  probability  of  strangu- 
lation more  and  more  unlikely.  I  believe  that  there  is  no  re- 
corded instance  of  implication  of  the  duodenum  in  this  form  of 
obstruction  ;  and,  indeed,  it  would  be  anatomically  impossible 
for  the  "  third  part "  of  that  segment  of  the  bowel  to  be  snared. 

The  frequency  with  which  the  last  few  feet  of  the  ileum 
are  involved  is  very  intelligible.  The  coils  of  the  lower 
ileum  are  the  parts  of  the  small  intestine  most  apt  to  be 
found  in  the  pelvis,  and  the  most  likely  therefore  to  be 
ensnared  by  those  many  adhesions  which  may  result  from 
pelvic  peritonitis.  They  are,  moreover,  in  the  closest  associa- 
tion with  the  cfecum  and  appendix,  and  are  most  apt  to  be 
strangulated  by  adhesions  that  may  follow  upon  perityphlitis, 
and  by  the  cord  formed  by  the  vermiform  appendix  when  it 
becomes  adherent.  Then,  again,  Meckel's  diverticulum  arises 
i'rom  the  lower  ileum,  and,  as  may  be  expected,  the  obstruc- 
tions that  it  causes  have,  with  comparatively  few  exceptions, 
their  seat  in  the  last  few  feet  of  the  lesser  boAvel.  In  strangu- 
lation due  to  this  process  the  part  of  the  ileum  involved 
may  be  either  that  above  or  that  below  the  origin  of  the 
abnormal  appendage.  In  most  cases  that  portion  of  the 
bowel  is  engaged  which  lies  between  the  diverticulum  and 
the  caecum.  It  must  also  be  noted  that  abnormal  apertures 
in  the  mesentery,  or  such,  at  least,  as  are  supposed  to  be  of 
congenital  origin,  are  most  often  found  in  that  part  of  the 
membrane  which  is  connected  with  the  lower  ileum.  This 
part  of  the  bowel,  moreover,  is  often  involved  in  hernias 
of  the  right  side,  and  may  suffer  in  any  trouble  due  to  bands 
of  adhesion  folloAving  upon  complicated  ruptures.  Lastly, 
it  is  to  be  observed  that  while  any  coil  of  small  intestine 
taken  from  the  upper  ileum  or  the  jejunum  would  be  equally 
movable  at  both  ends,  one  end  of  the  terminal  part  of  the 
ileum,  on  the  other  hand,  is  more  or  less  fixed  by  its  con- 
nection with  the  cfficum. 

As  to  the  amount  of  small  intestine  that  may  be  involved 
in  a  strangulation,  the  greatest  variety  exists.  The  involved 
piece,  on  the  one  hand,  may  be  so  small  that  only  one  half 
of  the  circumference  of  the  gut  is  nipped,"^  while  on  the  other 

*  Case  of  strangulation  uacler  an  omental  band,  by  Dr.  J.  Boeckel ;  Bull,  et 
Mem.  de  la  Soc.  de  Chir.,  tome  iv.,  1880,  p.  339. 


72  M  on  BID    ANATOMY. 

hand  it  may  measure  four  ieet.  Every  possible  variety  exists 
between  these  two  extremes.  Taking-  an  average  of  forU'-five 
causes  where  the  amount  of  bowel  mvolved  is  stated,  I  find 
that  it  reaches  15"5  inches.  The  amount  involved  depends  a 
great  deal  more  upon  the  mechanism  of  the  strangulation 
than  upon  the  anatomical  cause  of  it.  When  the  obstruction 
is  due  to  strangulation  under  a  band  or  through  a  slit  the 
average  amount  of  bowel  involved  is  small,  often  a  mere 
knuckle.  When,  on  the  other  hand,  the  strangulation  is 
brought  about  by  knots  and  nooses,  it  is  usually  found  that 
large  coils  are  involved,  it  being  impossible,  in  ordinary 
circumstances,  for  a  little  loop  of  bowel  to  be  so  strangulated. 

To  these  general  observations  there  are,  of  course,  many 
exceptions.  For  example,  one  of  the  cases  in  which  an 
unusually  large  amount  of  intestine  was  engaged  was  a  case 
of  strangulation  under  an  adherent  vermiform  appendix,  in 
which  instance  four  feet  of  ileum  were  found  to  be  implicated.* 
Examples,  also,  of  strangulation  of  two  and  even  three  feet  of 
bowel  beneath  a  band  are,  although  exceptional,  by  no  means 
uncommon. 

The  actual  mechanism  of  the  obstruction  varies  a  little 
in  different  cases.  In  many  instances  no  doubt,  a  knuckle 
or  coil  of  gut  is  driven  with  such  sudden  and  severe  force 
beneath  a  band  or  through  an  aperture  as  to  become  practic- 
ally strangulated  at  once,  just  as  is  the  case  in  strangulated 
hernia,  when  the  symptoms  appear  abruptly  during  some 
unwonted  exertion.  No  force  of  equal  magnitude  being 
brought  to  bear  upon  the  part  so  as  to  effect  its  reduction, 
it  remains  firmly  gripped.  When  a  comparatively  large  mass 
of  intestine  is  involved,  the  strangulation  need  not  be  present 
from  the  first.  But  the  band  pressing  upon  the  mesenteric 
vessels  produces  a  congestion  in  the  involved  coils  until  at 
last  the  engorgement,  aided  by  increasing  distension  of  the 
loop  itself,  leads  to  a  complete  strangulation.  (See  also  the 
account  gi\en  of  the  general  pathology  of  occlusion  of  the 
bowel,  page  9.) 

It  may  be  also  that  engorgement  of  the  veins,  and  a 
diminution  in  the  arterial  blood  supply  of  the  gut,  with 
consequent  deficiency  of  oxygen  and  excess  of  carbonic  acid 
in  such  blood  as  occupies  the  intestinal  walls,  induces  in- 
creased peristaltic  movements.  It  is  probable  that  these 
movements  materially  aid  in  producing  a  strangulation. 

Many  cases  are  on  record,  from  the  accounts  of  which  it 
is  to  be  inferred  that  vascular  distension  has  been  a  con- 
spicuous factor  in  completing  the  obstruction ;   cases  where 

*  l>r.  Hilton  Fagge ;  Guy's  Hosp.  liiporls,  vol.  xiv. 


MECHANISM    OF    OBSTRUCTION.  73 

much  gut  is  involved,  where  the  mesentery  is  extensively 
compressed,  and  where  a  bloody  fluid  in  the  peritoneum,  or 
many  haemorrhages  beneath  the  serous  coat,  point  to  the 
severity  of  the  congestion  which  preceded  actual  stopping 
of  the  circulation.  Increasing  distension,  moreover,  of  the 
implicated  bowel  must  alwa};s  be  an  important  feature.  This 
distension  is  due  not  so  much  to  matters  passed  into  the 
partly  occluded  intestine  from  above,  but  to  gas  developed 
within  the  strangulated  and  paralysed  loop. 

The  subject  of  meteorism  or  tympanitic  distension  of  the 
bowel  has  been  dealt  with  on  page  13.  The  part  such  dis- 
tension may  play  in  aidmg  and  increasing  the  process  of 
strangulation  is  demonstrated  by  certain  experiments.  M. 
Le  Moyne  opened  the  abdomen  in  the  cadaver,  and  having 
drawn  a  little  loop  of  the  small  intestine  through  a  slit 
made  in  the  mesentery,  replaced  the  gut  so  arranged  and 
closed  the  abdominal  wound.  He  then  made  a  second 
incision  into  the  belly  at  a  remote  spot,  and  injected  water 
or  semi-fluid  matter  into  the  small  intestine  above  the  seat 
of  the  obstruction.  The  first  matter  that  reached  the  loop 
in  the  mesentery  passed  through  it,  but  as  more  was  injected 
the  little  coil  became  rapidly  distended,  and  was  ultimately 
closed  and  entirely  obstructed.^  M.  Anger,  experimenting 
in  another  direction,  drew  a  loop  of  gut  out  of  the  abdomen, 
and  put  a  ligament  lightly  around  its  two  ends.  The  ligature 
was  loose  enough  to  allow  the  gut  to  slide  about  within  it, 
and  to  allow  the  tip  of  the  little  finger  to  be  introduced 
into  ea(;h  end  of  the  bowel.  He  then  made  a  hole  at  the 
bend  of  the  loop,  at  the  part  most  remote  from  the  ligature, 
and  introduced  a  tube,  through  which  air  was  blown.  As 
the  gut  distended  some  air  escaped,  but  the  more  swollen 
it  became  the  more  tightly  was  it  gripped,  until  when  fullj^ 
distended  it  was  found  to  be  hermetically  sealed ;  and,  what 
is  more  interesting,  more  gut  had  been  drawn  into  the  loop 
from  the  abdomen,  t 

In  a  great  many  cases  the  final  cause  of  the  strangulation 
is  a  twisting  or  volvulus  of  the  involved  coil  of  bowel.  This 
is  well  shown  in  several  museum  specimens.  Here  the  band 
would  not  have  been  of  itself  sufficient  to  produce  a  strangu- 
lation provided  that  the  bowel  had  not  become  twisted 
beneath  it.  On  the  other  hand,  it  is  equally  obvious  that  the 
volvulus   could   not   have  been  produced  without  the  Imnd. 

*  Contrib.  a  I'Etudc  de  I'Occlusion  Intestinale,  bv  M.  Le  Moviie.  Tbese  de 
Paris,  1878.^  "  -        ' 

t  Dc  rElranyiement  Jntestinale,  bv  ]\I.  Benjamin  AniJ-er.  These  de  Paris, 
1805. 


74  MORBID    ANATOMY, 

The  twist  is  given  to  the  bowel  partly  by  distension,  partly  by 
its  own  movements,  partly  by  the  drag-gino-  of  the  mesentery. 
In  some  cases,  adhesions  already  existing  above  the  implicated 
coil  may  have  favoured  the  volvulus.  There  must  be  cases 
also,  similar  to  that  illustrated  in  Fig.  5,  where  the  arrange- 
ment of  the  band  is  such  that  it  could  never  strangulate  the 
bowel  until  the  bowel  itself  had  become  twisted. 

There  are  instances  also  where  the  arrangement  of  the 
band  and  of  the  mesentery  is  such  that  the  engaged  loop  as 
it  becomes  distended  is  soon  so  acutely  bent  over  the  band  by 
the  dragging  of  the  mesentery  that  it  becomes  obstructed  (in 
one  end  of  the  loop  at  least)  before  it  is  very  tightly  gripjDed. 


CHAPTER  III. 

ANOMALOUS    FOllMS    OF    OBSTRUCTIOX    DUE    TO 
ISOLATED    BANDS    AND    ADHESIONS. 

Under  this  heading  may  be  grouped  a  remarkable  series  of 
cases,  all  more  or  less  infrequent,  in  which  an  obstruction  has 
been  brought  about  by  means  of  an  adherent  diverticulum,  or 
.  by  an  isolated  band,  or  by  more  extensive  adhesions,  but 
where  the  mechanism  of  the  occlusion  is  unlike  that  involved 
in  the  class  just  described. 

These  cases  are  united  by  a  common  pathological  bond, 
while  clinically  they  present  conspicuous  differences.  Unlike 
the  form  of  obstruction  just  discussed,  they  involve  the  large 
bowel  with  almost  as  great  a  frequency  as  they  involve  the 
small. 

As  all  these  cases  are  quite  rare  it  Avill  be  convenient  to 
deal  with  their  clinical  manifestations  at  the  same  time  that 
their  morbid  anatomy  is  considered,  inasmuch  as  it  is  scarcely 
possible  to  classify  them  in  a  satisfactory  manner  according 
to  their  symptoms. 

These  anomalous  cases  may  be  arranged  under  the  follow- 
ing headings : — 

L     Strangulation  over  a  band. 

2.  Occlusion  brought  about  by  acute  l-inkuir/  due  to  traction  upon 

an  isolated  band  or  an  adherent  diverticulum. 

3.  Obstruction  effected   by  adhesions  which  retain  the  bowel  in 

a  bent  position. 

4.  Obstruction  by  means  of  adhesions  which  compress  the  gut. 

5.  Obstruction  by  the  matting  together  of  several  coils  of  intestine. 

6.  Narrowing  of  the  bowel  from  shrinHng  of  the  mesenterij  after 

inflammation . 

I.  Strangulation  over  a  Band. — If  several  coils  of  a  thin 
indiarubber  pipe,  through  which  water  was  flowing,  were 
thrown  over  a  tightly  drawn  wire,  the  lumen  of  the  tube 
would  become  more  or  less  completely  occluded  at  the  spot 
where  the  wire  was  crossed.  It  is  conceivable  that  a  similar 
circumstance  may  be  met  with  in  the  abdomen  when  a  long 


76  MORBID    ANATOMY. 

loop  of  intestine  is  thrown  across  a  more  or  less  rigid  band. 
Here  the  weight  of  the  dependent  loops  would  act  as  a 
compressing  agent,  and  the  interference  with  the  circulation 
in  the  mesenteric  vessels  would  induce  an  engorgement  of  the 
involved  bowel.  It  is  difficult,  however,  to  understand  how 
such  a  form  of  obstruction  could  occur  in  the  living  subject 
without  some  arrangement  of  parts  which  would  permit  the 
dependent  coils  to  retain  their  position.  One  would  imagine 
that  a  little  vigorous  peristaltic  movement  would  soon  over- 
come the  occlusion,  on  the  one  hand,  and  withdraw  the 
intestine  from  its  abnormal  situation,  on  the  other ;  although 
it  is  more  than  probable  that  the  intestinal  contents  could 
enter  the  involved  loop  with  much  more  readiness  than  they 
could  leave  it.  I  have  found  records  of  four  cases  where  this 
form  of  obstruction  seems  to  have  taken  place,  and  in  one  onlj 
is  the  mechanism  of  the  occlusion  uncomplicated.  In  the 
simplest  case  a  diverticular  baud  passed  from  the  ileum  to  the 
umbilicus,  and  over  it  a  coil  of  ileum  from  two  to  three  feet  in 
length  was  found  to  have  been  flung  and  to  be  hanging  sus- 
pended. This  coil  was  intensely  congested,  and  numerous 
extravasations  had  taken  place  beneath  its  serous  coat. 
Symptoms  of  obstruction  appeared  suddenly  during  perfect 
health,  and  the  patient  only  lived  ten  hours.*  In  two  other 
instances  an  extensive  loop  of  the  lower  ileum  had  passed 
through  a  hole  in  the  omentum.  The  loops  were  black  with 
congestion,  and  were  hanging  down  into  the  pelvis.  In  one  case 
the  coil  was  fixed  in  this  position  by  recent  adhesions.  In  neither 
of  the  cases  was  the  obstruction  effected  by  the  aperture  itself, 
the  gut  being  very  readily  withdrawn  at  the  autopsy.  As  the 
author  of  one  of  the  cases  (Dr.  Fagge)  observes,  the  strangu- 
lation was  not  due  to  the  narrowness  of  the  aperture,  but  to 
the  hanofinof  of  the  o^ut  over  its  lower  edge.  In  both  cases  the 
symptoms  appeared  suddenly ;  in  both  acute  peritonitis  was 
found  at  the  post-mortem ;  in  both  the  patient  lived  five 
days.f  In  the  fourth  case  a  diverticulum  passed  to  be 
attached  to  the  umbilicus,  and  over  it  two  loops  of  the  ileum, 
black  with  congestion,  were  suspended.  They  were  found  to 
be  twisted  upon  themselves,  and  it  is  impossible  to  say  which 
was  the  primary  and  more  essential  phenomenon,  the  volvulus 
or  the  hanging  of  the  gut  over  the  cord.  The  symptoms 
appeared  suddenly,  acute  peritonitis  set  in  on  the  sixth  day, 
and  the  patient  died  on  the  ninth,  j 

*  De  rOcclusion  Intestinale,  by  Ur.  Lusseau.     Paris,  1879. 
t  Bull,  de  la  Soc.  Anat.,  p.  252;  Paris,  1864  ;  case  by  M.  Besnier.     And 
Guy's  Hosp.  Reports,  vol.  xiv.  ;  Dr.  Hilton  Fagge. 

I  Path.  Soc.  Trans.,  vol.  vii.,  p.  205  :  case  by  ilr.  Ward. 


OCCLUSION   BY   KINKING.  77 

In  a  drawing  of  a  case  of  strangulation  by  an  adherent 
diverticulum,  given  by  Bouvier,  it  would  appear  as  if  this 
form  of  obstruction  had  had  great  influence  in  producing 
the  fatal  result."^'" 

The  four  cases  all  occurred  in  males.  The  ages  were 
respectively  twenty-two,  forty-five,  and  sixty-five,  the  fourth 
case  being  met  with  in  "a  boy/' 

So  far  as  can  be  judged  from  these  few  cases,  the 
SYMPTOMS  resemble  those  of  hernia-like  strangulation,  a 
sudden  onset,  severe  pain,  collapse,  intense  and  persistent 
vomiting  (becoming  stercoraceous  in  at  least  one  instance), 
and  absolute  constipation.  In  the  case  fatal  in  ten  hours 
there  were  diarrhoea  and  profound  collapse.  The  main  points 
of  difference  between  these  cases  and  those  of  strangulation 
under  a  band  would  appear  to  consist  in  the  less  continuous 
character  of  the  pain  and  in  the  fact  that  the  symptoms 
all  advance  with  varying  intensity.  These  features  are 
intelligible  in  the  light  of  the  fact  that  the  obstruction  in 
these  cases  must  be  comparatively  incomplete,  while  the 
interference  with  the  blood  circulation  in  the  bowel  would 
lead  to  intense  venous  engorgement,  to  peristaltic  move- 
ments, and  local  meteorism. 

2.  Occlusion  by  Acute  Kinking  due  to  Traction. — In 
these  cases  a  band  attached  to  the  bowel 
so  drags  upon  its  point  of  attachment 
that  the  gut  becomes  acutely  bent  at 
this  spot,  and  is  ultimately  occluded  by 
a  process  akin  to  the  kinking  that  may 
close  an  indiarubber  tube  (Fig.  28).  This 
condition  is  usually  met  with  in  the  case 
of  a  diverticulum  or  diverticular  ligament  fig.  2.s. 

attached  to  the  umbilicus,  or  in  instances 
where  an  isolated  adhesion  is  connected  with  the  ileum  on 
the  one  hand  and  some  more  fixed  and  distant  point  on  the 
other.     The  shortness  of  the  mesentery  of  the  lower   ileum 
favours  the  formation  of  a  kink  in  that  part  of  the  bowel. 

Dr.  Eeignier  has  shown  that  it  is  possible  for  an  un- 
attached diverticle  to  cause  obstruction  by  kinking  if  the 
process  become  much  distended.  He  found  in  the  body  of 
an  infant  a  free  diverticulum  7  centimetres  long.  On  in- 
jecting water  into  the  gut  above  the  process,  he  found  that 
when  the  pressure  was  moderate  the  diverticle  simply  became 
filled,  and  that  the  fluid  passed  readily  by  it.  When,  how- 
.ever,  the  pressure  was.  much  increased,  the  process  dilated 
enormously,  and  so  pressed  upon    the  gut   below   its   point 

*  Bull,  de  TAcad.  de  iled.,  tome  xvi.,  p.  683,  18.51. 


78  MOBBID    ANATOMY. 

of  origin  as  to  bend  the  intestine  transversely,  and  finally 
occlude  its  lumen."^  He  gives  a  case  in  the  person  of  a 
man,  aged  twenty-two,  which  illustrates  this  experiment 
in  practice.  This  patient  died  after  exhibiting  for  ten  days 
the  symptoms  of  acute  intestinal  obstruction.  The  autopsy 
showed  a  free  diverticulum  which  was  much  dilated  by 
liquid  faeces,  and  which  had  so  acutely  bent  the  gut  from 
which  it  arose  that  the  lumen  of  the  intestine  was  quite 
closed.  On  lifting  the  diverticle  and  gently  pressing  it,  the 
obstruction  was  overcome.     {See  page  51.) 

A  specimen  (No.  2695a)  in  the  Royal  College  of  Surgeons 
Museum  shows  a  diverticulum  which  had  caused  such  an 
acute  bending  of  the  ileum  from  which  it  sprang  as  to  occlude 
it.  The  patient  was  a  middle-aged  man,  who  was  seized 
with  S3^mptoms  of  acute  obstruction  quite  suddenl}^  He 
died  in  five  days,  a  laparotomy  having  failed  to  reveal  the 
cause  of  the  obstruction. 

In  cases  of  kinking  by  adherent  diverticula  and  bands 
it  is  probable  that  distension  of  the  bowel  may  be  active 
in  bringing  the  obstruction  about.  Moreover,  disteaded 
coils  of  intestine  may  press  upon  the  ligament  itself,  and 
so  cause  it  to  be  stretched. 

The  following  are  some  examples  of  kinking  produced 
by  isolated  adhesions  :  In  a  case  by  Louis  a  band  was  found 
to  pass  between  an  ovarian  cyst  and  the  lower  ileum.  When 
the  cyst  was  emptied  by  a  trochar  the  band  was  stretched 
and  so  dragged  upon  the  bowel  that  it  was  closed,  and 
symptoms  of  intestinal  obstruction  developed.  Heller  reports 
a  case  where  a  loop  of  the  lesser  bowel  was  adherent  to  a 
gTavid  uterus.  After  delivery  the  traction  upon  the  intestine 
was  such  that  it  became  acutel}^  bent  and  occluded.  "  Warren 
saw  a  pedunculated  subperitoneal  fibroid  of  the  uterus 
so  wedged  in,  in  consequence  of  a  sudden  change  of  position, 
between  the  wall  of  the  pelvis  and  a  false  ligament  stretched 
from  the  lowest  part  of  the  ileum  to  the  uterus,  that  the 
former  was  bent  and  occluded  by  the  traction  of  the  band 
attached  to  it."t  Dr.  Hilton  Fagge  records  the  case  of  a 
little  girl,  aged  nine,  in  whose  abdomen  at  the  autopsy  man}^ 
old  adhesions  were  found  resulting  from  a  local  peritonitis 
set  up  by  tuberculous  disease  of  the  mesenteric  glands. 
Some  adhesions  passed  between  the  sigmoid  flexure  and  the 
ileum,  others  between  the  latter  bowel  and  the  omentum ; 
while  the  mesentery  was  so  much  shrunken  as  to  bind  the 
small   intestine  closer   to  the   spine.     The  immediate  cause 

*  Bull,  de  la  Soc.  Anat.,  p.  279.     Paris,  1879. 
t  Leichtenstern,  loc.  c;t.,  p.  530. 


OCCLUSION   BY   KINKING.  79 

of  obstruction  seems  to  have  been  due  to  a  band  which  fixed 
the  small  intestine  to  the  liver,  and  which  caused  great  angular 
bending  of  the  bowel.  At  this  bend  the  empty  and  the 
distended  coils  met,  while  above  that  point  was  a  perforation 
in  the  jejunum.^ 

One  of  the  best  examples  of  obstruction  by  kinking  due 
to  an  adherent  diverticle  is  given  by  Dr.  Wilks,  The  process 
in  this  case  was  attached  to  the  umbilicus,  and  had  been 
so  stretched,  probably  by  the  meteoristic  state  of  the  gut, 
that  it  had  become  torn,  and  so  had  induced  peritonitis,  t 
The  gut  was  normal  at  the  seat  of  the  acute  bend,  as  indeed 
it  appears  to  have  been  in  all  the  cases  belonging  to  this 
category.  In  Dr.  Wilks's  case  the  dragging  of  the  empty  and 
pendulous  coils  below  the  attachment  of  the  diverticle  appears 
to  have  helped  in  maintaining  the  obstruction.  Dr.  Turner 
reports  an  acute  case  of  kinking  in  a  boy  aged  ten.  The 
diverticular  band  was  adherent  to  the  umbilicus.  There 
was  a  sharp  flexion  of  the  ileum  at  the  point  of  origin  of 
the  diverticulum  caused  by  the  passage  of  the  coils  im- 
mediately above  it  behind  the  cord  from  left  to  right.  There 
was  much  traction  upon  the  ileum.  The  bowel  thus  narrowed 
by  kinking  was  finally  blocked  by  a  plum  stone.  |  In  the 
museum  of  the  Royal  College  of  Surgeons  §  is  a  specimen 
showing  a  coil  of  small  intestine  adherent  to  the  abdominal 
Avail,  and  very  sharply  bent  at  the  point  of  adhesion.  The 
specimen  was  from  the  body  of  a  lady  aged  forty-five,  who 
four  days  after  ovariotomy  developed  symptoms  of  acute 
obstruction,  of  which  she  died  in  three  daj^s.  The  obstruc- 
tion was  due  to  acute  kinking  of  the  adherent  bowel.  Dr. 
Quain||  reports  the  following  case  in  a  woman  aged  fifty- 
three  :  A  large  perinephritic  abscess  had  been  opened,  to 
the  wall  of  which  the  descending  colon  was  adherent.  The 
patient  died  with  symptoms  of  obstruction  lasting  twelve 
days.  The  adherent  colon  was  found  to  have  been  so 
bent  by  the  collapse  of  the  abscess  wall  as  to  have  become 
occluded. 

In  a  case  under  my  care  I  evacuated  a  large  perityphlitic 
abscess  which  had  existed  for  some  time.  Symptoms  of 
intestinal  obstruction  of  a  subacute  character  followed  the 
operation.  I  opened  the  abdomen,  and  found  that  a  coil 
of  small  intestine  had  become  adherent  to  the  abscess  "  wall," 


*  Path.  Soc   Trans.,  vol.  xxvii.,  p.  157. 

t  Ibid.,  vol.  xvi.,  p.  126. 

t  Path.  Soc.  TraES.,  1881,  p.  86. 

§  No.  2692. 

II  Path.  Soc.  Trans.,  vol.  v.,  p.  179. 


81)  MORBID    ANATOMY. 

and  had  been  kinked  by  the  collapse  of  that  wall  after 
the  pus  had  been  evacuated.  The  releasing  of  this  coil  put 
an  end  to  the  obstruction  symptoms. 

During  the  progress  of  tuberculous  peritonitis,  and  par- 
ticularlj^  during  the  period  when  recovery  is  taking  place, 
minor  obstructive  attacks  may  occur  which  are  possibly  due 
to  kinking.  As  illustrative  of  the  association  between  peri- 
tonitis and  kinking  of  the  bowel  may  be  mentioned  cases 
reported  by  Paul"^  and  CaA'e.t 

The  symptoms  due  to  kinking  of  the  bowel  are  in  the 
main  very  similar  to  those  which  attend  strangulation  under 
a  band.  The  onset  is  usually  less  abrupt.  Very  often  there 
have  been  many  minor  attacks,  or  the  final  attack  may  have 
been  preceded  by  colic,  constipation,  and  vague  intestinal 
uneasiness.  The  progress  of  the  case  is  less  acute  than  in 
strangulation  by  a  band,  patients  living  eleven,  fifteen,  and 
twenty  days  in  some  instances.  In  Dr.  Turner's  case  alluded 
to  above  the  trouble  proved  fatal  on  the  fourth  day. 

The  symptoms  also  are  such  as  would  suggest  that  the 
occlusion  is  not  absolute.  The  pain,  although  severe,  will 
present  very  unequal  degrees  of  intensity ;  the  vomiting, 
although  often  incessant,  distressing  and  stercoraceous, 
may  abate ;  the  meteorism,  even  in  cases  of  long  duration, 
may  be  quite  slight.  The  constipation,  moreover,  although 
usually  complete,  may  yield  a  little,  and  the  bowels  be 
opened  by  an  aperient  even  when  the  symptoms  of  obstruc- 
tion have  lasted  eight  days,  as  in  Dr.  Fagge's  case. 

In  some  instances  there  has  been  some  diarrhoea.  The 
symptoms  are  occasionally  curiously  relieved  by  posture, 
and  in  a  great  many  of  the  cases  there  is  a  tendency  to 
relapse.  In  a  few  of  the  more  chronic — or  rather  of  the 
less  acute — cases  I  have  seen  evidence  of  some  little  hyper- 
troph}^  of  the  bowel.  In  such  rare  instances  there  may  be 
much  nunbling  and  gurgling  in  the  abdomen. 

3.  Obstruction  by  Adhesions  which  Retain  the  Bowel 
in  a  Bent  Position. — These  cases,  whicli  are  not  uncommon, 
concern  both  the  large  and  the  small  intestine.  The  gut  is 
found  to  have  become  adherent  to  some  fixed  point  in  such 
a  way  that  a  more  or  less  acute  bend  is  produced. 

The  site  of  the  adhesion  is  usually  on  the  abdominal  or 
pelvic  parit/tes  or  on  the  pelvic  viscera.  It  may  be  on  the 
liver.  The  usual  causes  of  the  adhesion  are  hernia,  peri- 
typhlitis, pelvic  peritonitis,  peritonitis  due  to  injury,  to  opera- 
tion, to  ulceration  of  the  gall  bladder  or  of  the  bowel. 

*  Lancet,  1894,  vol.  i.,  p.  609. 

+  Jh-it.  Med.  Jonrn.,  1891,  vol.  ii.,  p.  67. 


OBSTRUCTION   BY   ADHESIONS.  81 

In  the  cases  which  have  followed  hernia  the  part  of 
bowel  adherent  is  the  same  which  had  occupied  the  rupture. 
The  condition  is  met  with,  therefore,  only  after  enteroceles, 
and  only  after  such  as  have  been  strangulated  or  inflamed. 
The  bcfvel,  presenting  in  any  case  some  inflammation  of  its 
serous  coat,  is  reduced  into  the  abdomen,  and  instead  of 
remaining  free  in  that  cavity,  contracts  adhesions  by  means 
of  its  inflamed  surface  with  some  other  part  of  the  peri- 
toneum. 

In  every  case  of  this  kind,  so  far  as  I  am  aware,  the 
adhesion  of  the  bowel  has  been  to  the  parietes  in  the  vicinity 
of  the  hernial  orifice. 

As  an  illustration  of  this  fact  may  be  cited  a  case  recorded 
by  Mr.  Jones."^ 

The  bowel,  having  been  recently  herniated,  usually 
acquires  an  adhesion  in  a  bent  position,  and  when  so  fixed 
often  leads  to  further  intestinal  troubles,  in  cases  where 
strangulated  or  inflamed  herniae  have  been  successfully 
reduced.  The  condition  usually  occurs  after  femoral 
ruptures. 

Quite  a  large  number  of  these  cases  depend  upon  the 
adhesions  which  may  follow  upon  perityphlitis.  I  have 
met  with  instances  in  which  acute  obstruction  has  followed, 
and  others  in  which  the  patient  had  had  repeated  minor 
attacks,  or  presented  symptoms  which  might  be  termed 
chronic.  A  good  instance  of  an  acute  attack  depending 
upon  adhesions  set  up  by  a  diseased  appendix  is  reported 
by  Mr.  Chejme.t  The  patient  was  operated  upon  thirty-six 
hours  after  the  most  acute  symptoms  had  set  in,  and  made 
a  good  recovery. 

So  many  of  the  exainples  of  the  present  form  of  obstruc- 
tion depend  upon  pelvic  peritonitis  that  the  majority  of  the 
subjects — taking  the  whole  series  together — -are  found  to  be 
females.  This  disposition  to  one  particular  sex  is  further 
emphasised  by  the  cases  which  have  followed  upon  ab- 
dominal operations,  and  upon  troubles  incident  to  gall 
stones.  The  cases  in  males  are  largely  made  up  by  such 
as  have  followed  upon  perityphlitis.  In  one  recorded  case 
in  a  man  the  adhesions  which  caused  the  obstruction  had 
followed  upon  a  little  peritonitis  excited  by  tapping  the 
bladder  above  the  pubes.+ 

I  have  met  with  a  case  in  a  male  subject  in  which  a  coil 
of  jejunum  had  become  adherent  to  an  inflamed  gall  bladder 

*  Lancet,  1891,  vol.  i.,  p.  1370. 
t  Brit.  Med.  .Jonrn.,  1894,  vol.  i.,  p.  967. 
X  Dr.  Briddon,  Xew  York  Med.  Jouni.,  1882,  p.  116. 
G    ' 


82  MORBID    AXATOMY. 

— from  which  a  gall  stone  was  escaping — and  had  become 
thereby  occluded. 

In  very  many  of  the  cases  the  hepatic  flexure  of  the 
colon  is  adherent  in  the  vicinity  of  the  gall  bladder  as 
a  result  of  hepatitis,  due  in  most  cases  to  gall  stones. 

It  is  needless  to  say  that  practically  all  the  subjects  of 
the  present  form  of  obstruction  are  adults.  Indeed,  the 
youngest  patient  of  whom  I  have  any  note  is  a  woman  of 
thirty. 

The  involved  gut  is  usually  adherent  at  one  isolated 
spot  only,  and  a  single  and  simple  angular  bend  is  thus 
produced.  This  is  the  condition  met  with  in  those  cases 
which  depend  upon  hernia.  In  other  instances  the  attach- 
ment may  be  more  extensive,  as  in  a  case  of  Dr.  Fagge's, 
where  one  foot  of  the  lower  ileum  was  found  adherent  to 
the  anterior  abdominal  parietes  as  a  result  of  omental 
sarcoma.  Moreover,  the  bends  formed  in  the  bowel  may  be 
by  no  means  simple.  There  may  be  several  angular  bends, 
the  loops  being  adherent  at  more  points  than  one,  and 
made  to  assume  the  outline  of  the  letter  N."^  This  arrange- 
ment may  be  still  further  complicated  by  the  matting  together 
of  the  three  bars  of  the  intestinal  N,  whereby  the  false 
position  is  perpetuated.  In  one  case  where  N-like  bends 
were  produced  only  four  inches  of  bowel  were  involved,  so 
that  the  angles  formed  were  very  acute  and  abrupt.t 

A  few  examples  may  be  given  to  illustrate  the  varieties 
assumed  by  this  form  of  intestinal  obstruction.  The  con- 
vexity of  the  ascending  colon  may  become  adherent  to  the 
ovary,  and  the  gut  be  so  narrowed  at  the  bend  as  barely 
to  admit  a  crow-quill.J  The  transverse  colon  may  become 
adherent  to  the  fundus  uteri.  § 

The  rectum  may  attach  itself  to  a  cancerous  ovary,  and 
present  in  consequence  a  very  angular  bend.jl  The  sigmoid 
flexure  may  adhere  to  a  uterus  the  seat  of  a  malignant 
disease,  and  present  so  abrupt  a  bend  that  fatal  obstruction 
with  symptoms  like  those  of  volvulus  may  ensue. ^ 

The  period  of  time  that  may  intervene  between  the  for- 
mation of  the  adhesion  and  the  occurrence  of  symptoms 
of  intestinal  obstruction  varies  greatly.  In  the  case  fol- 
lowing aspiration  of  the  bladder  just  alluded  to,  evidences 

*  Case  by  M.  Cossy,  quoted  by  M.  Nouet  ;  De  I'Occhision  Intestinale  dans 
«ies  Eapports  avec  les  Inflammations  peri-uterines  chroniques.     Paris,  1874. 
t  Louis  ;  Archiv.  Gen.  de  Med.,  P^  Serie,  tome  xiv.,  p.  193. 
X  Duchanssoy,  Mem.  sur  I'Anat.  Path,  des  Etrang.  Internes,  1860. 
§  Dr.  Hilton  Fagge,  loc.  cit. 
II   Path.  See.  Trims.,  vol.  xvi.,  p.  197. 
^  M.  Cossy ;  Mom.  de  la  Soc.  d'Observat.,  1856,  tome  iii. 


OBSTRUCTION    BY   ADHESIOXS.  83 

of  obstruction  appeared  Avithin  a  lew  days  of  the  original 
lesion. 

Harrison  Cripps  ■^  has  published  a  case  where  acute 
obstruction  set  in  eighteen  days  after  the  removal  of  a 
large  fibroid  growing  beneath  the  broad  ligament.  The 
adhesions  proved  so  inseparable  from  a  coil  of  bowel  that 
the  damage  inflicted  upon  the  latter  necessitated  the  for- 
mation of  an  artificial  anus. 

In  the  majority  of  cases  the  intestinal  symptoms  do  not 
make  their  appearance  until  months  after  the  initial  peri- 
tonitis. In  a  case  under  my  care  in  which  symptoms  of 
chronic  obstruction  were  due  to  the  fact  that  the  transverse 
colon  was  adherent  to  the  uterus,  the  obstruction  symptoms 
appeared  two  months  after  the  subsidence  of  the  peri- 
metritis which  led  to  the  adhesion.  In  this  instance  I  set 
free  the  bowel,  and  the  patient  made  a  good  recovery. 
I  think  that  in  the  cases  due  to  hernia  a  somewhat  earlier 
appearance  is  usual,  a  matter  in  many  instances  of  weeks 
rather  than  of  months.  Sometimes  years  have  elapsed 
between  the  causative  inflammation  and  the  symptoms  of 
obstruction,  such  examples  being  most  usual  in  the  large 
intestine.  Many  of  the  patients  have  been  the  victims  of 
chronic  constipation  for  years  before  the  final  occlusion 
occurred.  At  the  same  time  it  must  be  noted  that  ad- 
hesions of  a  like  character  to  those  now  under  consideration 
have  been  met  with  in  the  autopsies  of  patients  who  pre- 
sented no  marked  intestinal  symptoms  during  life. 

The  mechanism  of  the  obstruction  in  these  cases 
varies,  and  may  be  conveniently  considered  under  three 
categories,  taken  in  order  of  severity. 

A.  The  gut  at  the  adherent  point  may  become  so  bent 
that  occlusion  by  kinking  is  produced.  This  is,  as  a  rule, 
met  with  in  the  colon.  The  symptoms  induced  are  severe 
and  sudden  in  their  onset.  Their  abrupt  development 
possibly  depends  upon  sudden  occlusion  at  the  bend, 
brought  about  by  some  distension  of  the  bowel,  or  some 
change  in  its  position. 

B.  The  bowel  (a  portion  always  of  the  small  intestine) 
is  adherent  over  a  small  area,  and  symptoms  of  obstruction 
follow  Irom  certain  effects  of  traction  without  conspicuous 
occlusion  of  the  lumen  of  the  tube.  It  is  certain  that,  so 
far  as  the  lesser  bowel  is  concerned,  mere  adhesion  over  a 
limited  district  tends  to  cause  an  impediment  to  the  passage 
of  matter.  The  gut  at  the  adherent  spot  cannot  exercise 
its   peristaltic   function.     It   becomes   a  more   or    less    inert 

*  Brit.  Med.  Journ.,  1894,  vol.  ii.,  p.  1103. 


84  MORBID    ANATOMY . 

segment  in  an  active  tube.  If"  a  little  acute  mischief  be 
excited  about  the  seat  of  the  adhesions,  symptoms  of  an 
acute  or  subacute  character  may  arise,  the  exact  pathogenesis 
of  which  is  a  little  obscure.  That  form  of  rupture  known 
as  Richter's  hernia  throws  some  light  upon  these  cases.  In 
this  hernia  the  gut  is  tightly  held  down,  a  part  only  of  its 
circumference  is  nipped,  and  yet  symptoms  of  acute  intestinal 
obstruction  follow,  the  greater  part  of  the  lumen  of  the  bowel 
being  at  the  time  often  quite  unoccluded.  It  is  evident  in 
this  form  of  hernia  that  the  main  lesion  is  not  the  narrow- 
ing of  the  lumen  of  the  bowel,  but  the  sudden  and  severe 
injury  inflicted  upon  the  peritoneal  nerves  by  the  strangu- 
lation. The  bowel — although  not  occluded — is  held  in  a 
fixed  position  and  is  damaged. 

Supposing  a  patient  to  have  a  loop  of  intestine  ad- 
herent to  the  parietes,  and  that  some  little  inflammatory 
trouble  is  excited  about  the  adherent  knuckle,  it  would 
seem  as  if  symptoms  of  subacute  obstruction  could  arise 
from  somewhat  parallel  conditions  to  those  that  produce 
the  manifestations  in  Richter's  hernia.  In  the  case  follow- 
ing aspiration  of  the  bladder  some  local  peritonitis  kept 
up  after  the  gut  had  become  adherent  was  apparently 
sufficient  to  lead,  in  combination  with  the  bent  bowel,  to 
rather  acute  evidences  of  obstruction.  In  other  instances 
violent  peristaltic  movements,  such  as  may  occur  during 
colic  or  diarrhoea,  may  cause  a  rough  dragging  upon  the 
attached  intestine,  and  so  add,  as  it  were,  the  fuse  to  a 
train  already  prepared.  The  effect  of  a  little  local  peritonitis 
in  rendering  a  peritoneal  obstruction  an  actual  one  is  often 
illustrated.  As  one  example  I  might  cite  the  following :  An 
old  man  was  admitted  into  the  London  Hospital  under  the 
care  of  Mr.  Rivington.  The  patient  had  received  a  blow 
upon  the  abdomen.  A  few  days  after  admission  he  de- 
veloped symptoms  of  acute  obstruction,  of  which  he  died  in 
less  than  two  days.  At  the  autopsy  the  transverse  colon  was 
found  to  be  bent  upon  itself  and  retained  in  that  position 
by  old  adhesions.  In  no  place  Avas  the  lumen  of  the  bowel 
occluded.  The  peritoneum  was  healthy  save  at  one  spot 
over  the  liver  where  there  was  a  little  local  peritonitis.* 

As  regards  the  cases  now  under  notice,  it  can  only  be  said 
that  patients  may  die  of  more  or  less  acute  obstruction,  and 
exhibit  at  the  autopsy  an  adherent  and  bent  intestine  about 
which  some  little  peritoneal  mischief  is  evident,  while  the 
lumen  of  the  bowel  is  at  no  point  wholly  or  even  nearly 
occluded. 

*  For  an  account  of  this  case  see  page  100. 


i 


OBSTRUCTION   BY   ADHESIONS.  85 

C.  The  adherent  bowel  may  offer  a  more  or  less  definite 
mechanical  obstacle  to  the  passage  of  its  contents.  A  part 
of  the  colon  may  present  so  sharp  and  rigid  a  bend  as  to 
give  to  the  involved  intestine  the  properties  of  a  stricture. 
This  condition  is  well  illustrated  by  a  case  reported  by  Dr. 
Owen  Rees,  where  the  rectum  was  so  involved."^  In  other 
instances  the  bowel,  and  particularly  the  lesser  bowel,  is 
adherent  over  a  wide  area,  and  the  mere  mertness  of  the 
attached  portion  constitutes  an  obstruction.  This  is  well 
seen  in  those  cases  where  the  bowel  is  adherent  in  a  contorted 
position,  as  when  it  assumes  an  N-like  outline  and  the  limbs 
of  the  N  are  bound  together,  or  when  several  inches  of  it  are 
blended  in  a  straight  line  with  the  parietes,  as  in  Dr.  Fagge's 
case  quoted  above.  Here  the  bowel  above  the  diseased  part 
has  not  only  to  pass  its  own  contents  along,  but  has  to  force 
them  also  through  the  inert  and  adherent  seg-ment.  The 
longer  this  segment  the  more  marked  the  obstruction.  When 
closely  bound  do^\Tl,  the  involved  gut  must  be  practically 
incapable  of  peristaltic  movement,  and  must  be  to  the  rest  of 
the  boAvel  as  a  piece  of  thin  indiarubber  tubing.  Pathological 
reports  and  museum  specimens  well  illustrate  this.  The 
adherent  bowel  is  either  of  normal  aspect  or  is  abnormally 
thin,  while  the  intestine  above  it  shows  a  hypertrophy  of  its 
Avails  that  may,  in  some  instances,  be  extreme.t  The  gut, 
moreover,  just  above  the  inert  part  often  shows  some  ulcera- 
tion of  the  mucous  membrane,  due  presumedly  to  the  irrita- 
tion of  accumulated  matters.  The  hypertrophy  is  all  in  the 
muscular  coat  and  compares  conspicuously  with  the  thin 
walls  of  the  inert  and  adherent  segment.  Moveover,  when 
there  is  much  angular  bending  of  the  gut  the  contents  of 
the  bowel  have  to  be  not  only  forced  through  an  inert  tube, 
but  have  to  take  a  devious  course  and  encounter  certain 
definite  obstructions. 

The  symptoms  associated  with  these  different  forms  of 
obstruction  will  obviously  show  great  variation.  They  may 
assume  an  acute,  or  a  subacute  or  a  chronic  aspect,  and 
will  differ  according  to  whether  the  occlusion  is  situate  in 
the  large  or  the  small  intestine. 

A.  In  the  colon. — If  the  obstruction  be  due  to  a  sudden 
closure  of  the  gut  by  kmking  at  the  already  bent  and 
adherent  part,  the  sjmiptoms  may  be  of  a  very  acute 
character.  The  condition  appears  to  occur  most  usually  in 
connection  with  the  sigmoid  flexure  or  upper  part  of  the 
rectum,  and  the  manifestations  produced  may  be   identical 

*  Jled.  2'ime-s  and  Gaze  te,  vol.  i.,  1869    p.  136. 
t  Hee  case  by  Louis  quoted  above. 


86  MORBID    ANATOMY. 

with  those  due  to  volvukis  of  the  former  segment  of  the 
bowel.  I  might  give  one  ilkistration.  A  woman,  aged  forty- 
four,  was  admitted  into  the  London  Hospital  under  my  care 
suffering  from  symptoms  of  acute  obstruction.  These  symp- 
toms had  appeared  suddenly  after  taking  an  aperient.  They 
were  precisely  the  symptoms  of  volvulus  of  the  sigmoid 
flexure.  The  patient  had  been  the  subject  of  some  constipa- 
tion for  years,  and  had  had  attacks  of  colic  occasionally.  In 
twenty-four  hours  after  the  onset  the  woman  was  in  a  pre- 
carious condition.  I  performed  laparotomy,  but  she  died 
twelve  hours  afterwards.  The  commencement  of  the  rectum 
or  terminal  part  of  the  sigmoid  flexure  was  adherent  to  one 
point  of  the  pelvic  wall  in  a  bent  position.  The  bend  here  had 
become  so  extreme  that  the  gut  was  entirely  occluded.  The 
colon  above  w^as  enormously  distended  and  the  sigmoid 
flexure  reached  to  the  right  of  and  above  the  umbilicus.  On 
emptying  the  colon  by  puncture,  and  breaking  through  the 
adhesions,  the  passage  in  the  bowel  was  soon  restored. 

The  symptoms  may  be  subacute,  as  in  a  case  reported  by 
M.  Cossy,  where  the  sigmoid  flexure  was  adherent  to  a 
cancerous  ovary.  Here  the  final  attack  lasted  some  eight  or 
nine  da3^s,  and  was  marked  by  paroxysmal  pain  with  visible 
peristalsis,  by  slight  non-stercoraceous  vomiting,  and  by  con- 
stipation relieved  by  an  occasional  stool. 

In  other  instances  the  manifestations  may  be  quite 
chronic,  and  may  resemble  in  all  points  those  due  to  stricture 
of  the  rectum  or  lower  part  of  the  colon.  A  case  of  this 
character  has  been  reported  by  Mr.  Heath.  He  performed 
lumbar  colotomy  on  the  twentieth  day  of  the  constipation. 
The  rectum  was  adherent  to  the  uterus  and  ovary  (which 
w^as  the  seat  of  cancer),  and  w^as  bent  into  a  sharp  sigmoid 
form.^ 

In  a  case  of  my  own  of  adhesion  of  the  transverse 
colon  to  the  uterus,  to  which  I  have  already  alluded  (page 
83),  the  symptoms  of  chronic  obstruction  had  existed  for 
two  and  a  half  years  before  the  operation  was  performed. 

B.  In  the  small  intestine. — The  symptoms,  Avhen  the 
obstruction  is  in  this  part  of  the  bowel,  may  also  be  either 
acute  or  chronic.  A  more  or  less  typical  example  of  each  form 
may  be  given.  I  saw,  in  consultation  with  Dr.  Towne,  of  Kings- 
land,  a  woman  aged  fifty-eight,  who  three  months  previously 
had  had  some  inflammation  about  a  small  femoral  hernia. 
The  bowel  was  reduced  at  the  time,  and,  to  her  surprise,  had 
never  come  dow^n  again,  nor  given  her  any  trouble.  She 
was,   when    seen,   suffering  from  intestinal  obstruction ;   the 

*  P;ith.  Soc.  Trans.,  vol.  xvi.,  j).  197. 


OBSTRUCTION   BY   ADHESIONS.  87 

onset  had  not  been  sudden.  She  had  much  pain  of  a 
markedly  paroxysmal  character.  She  vomited  at  first  at  long 
intervals,  bringing  up  large  quantities  of  matter.  As  the  case 
progressed  the  vomiting  became  more  frequent  (every  two  or 
three  hours)  and  stercoraceous.  She  had  constipation  that 
was  absolute  but  for  one  slight  liquid  motion  passed  during 
the  first  few  days  of  the  attack.  I  performed  laparotomy 
on  the  seventh  day,  and  found  a  coil  of  greatly  distended 
ileum  adherent  in  a  bent  position  to  the  vicinity  of  the  femoral 
ring.  The  adhesions  retaining  it  were  readily  broken  down 
and  the  abdomen  then  closed.  She  never  vomited  after  the 
operation ;  a  copious  motion  was  passed  on  the  fourth  day,  and 
the  patient  made  a  perfect  recovery. 

In  Dr.  Fagge's  case,  quoted  above,  where  a  foot  of  the 
ileum  was  adherent  to  the  parietes,  the  symptoms  lasted  some 
five  months.  There  were  constipation  that  alternated  with 
diarrhoea,  vomiting  that  appeared  late  in  the  case,  and  that 
came  on  once  or  twice  in  the  twenty-four  hours  (the  patient 
bringing  up  immense  quantities  each  time)  and  pain  of  a  very 
marked  paroxysmal  character.  There  was  a  dragging  pain 
about  the  lower  part  of  the  abdomen.  The  vomited  matters 
became  stercoraceous  six  days  before  death. 

It  will  be  seen  that  in  both  cases  there  were  evidences  of 
incomplete  obstruction.  The  constipation  alternated  with  an 
occasional  motion.  In  some  of  the  other  less  acute  cases  the 
patient,  when  not  absolutely  constipated,  passed  many  scanty 
and  very  liquid  stools. 

The  vomiting  is  not  severe  at  first,  and  occurs  at  long 
intervals.  The  abdominal  pain  is  paroxysmal.  There  is  a 
dragging  pain  about  the  part  to  which  the  gut  is  adherent. 
There  is  not  much  distension  of  the  abdomen. 

In  one  instance,  where  the  ileum  was  adherent  to  the 
ovary  and  formed  many  angular  bends,  an  irritable  diarrhoea 
took  the  place  of  the  more  usual  constipation,  and  the  patient 
only  vomited  twice  during  the  month  that  immediately 
preceded  her  death.  Such  a  case  hardly  comes  clinically  under 
the  category  of  intestinal  obstruction. 

In  the  more  chronic  cases  the  symptoms  are  in  all  par- 
ticulars identical  with  those  of  stricture  of  the  bowel. 

There  are  the  same  colic,  the  same  form  of  vomiting, 
and  the  same  hypertrophy  of  the  bowel  above  the  stenosed 
part.  Such  cases,  indeed,  are — so  far  as  their  mechanism 
is  concerned — identical  with  those  of  stricture  of  the 
bowel. 

The  form  of  intestinal  obstruction  now  under  considera- 
tion  is   apt,   both   when   the   small  and   the   large   gut   are 


88  MOB  BID    ANATOMY. 

involved,  to  appear  in  paroxysms  or  repeated  attacks  asso- 
ciated in  the  intervals  between  the  relapses  by  periods  of 
more  or  less  abdominal  uneasiness. 

4.  Obstruction  by  Means  of  Adhesions  that  Compress 
the  Gut. — Peritoneal  adhesions,  when  favourably  placed,  may 
undergo  considerable  contraction.  When  placed  upon  the 
bowel,  these  false  membranes  may,  in  very  rare  instances,  by 
their  shrinking,  so  compress  the  intestine  as  to  narrow  its 
lumen.  This  form  of  constriction,  rare  as  it  is,  is  most 
usually  met  Avith  about  the  most  fixed  segments  of  the 
intestine,  that  is  to  say,  about  the  ascending  and  descending 
colon,  and  the  hepatic  and  splenic  flexures.  The  process 
involved  in  certain  of  these  cases  where  the  colon  is  con- 
cerned is  thus  described  by  Leichtenstern :  "  A  circumscribed, 
chronic,  constricting  peritonitis  is  sometimes  found  at  the 
flexures  of  the  colon.  As  the  results  of  atony  of  the  muscular 
coat  repeated  faecal  accumulations  are  found,  especially  at  the 
flexures,  the  points  where  the  obstacles  to  the  advance  of 
the  fseces  are  greater.  The  frequently  repeated  irritation  of 
the  peritoneum  produced  thereby  excites  chronic  peritonitis, 
which  may  result  in  constriction.  In  other  cases  the  chronic 
peritonitis  starts  from  the  concavity  of  the  liver  and  extends 
to  the  flexura  hepatica;  it  is  set  up  at  the  former  point  by 
gall  stones,  etc.,  or  is  the  continuation  of  a  cirrhotic  process 
in  the  liver,  or  of  a  portal  periphlebitis.  In  the  left  hypo- 
chondrium  we  sometimes  find,  together  with  numerous 
splenic  adhesions  and  fibrous  perisplenitis,  the  splenic  fiexure 
adherent  and  constricted  by  chronic  fibrous  peritonitis.""^ 
It  is  more  than  probable  that  the  examples  met  with  about 
the  colic  flexures  are  due  to  the  cicatrisation  of  non- 
malignant  ulcers,  and  especially  of  the  "  stercoral  ulcer."  In 
other  instances  the  cause  of  the  constricting  peritonitis  is 
not  so  evident.  An  example  of  such  a  case  is  aflbrded  by 
a  specimen  in  the  London  Hospitalt  (Fig.  29).  Here  the 
ascending  colon  just  above  the  csecum  is  narrowed  by  an 
isolated  patch  of  contracting  adhesions  so  as  to  produce 
considerable  stenosis.  It  is  probable  that  in  this  case,  and 
in  others  like  it,  the  limited  peritoneal  inflammation  has  been 
induced  by  an  ulcer  of  the  mucous  membrane,  although  the 
evidence  of  this  in  the  present  specimen  is  wanting.  The 
association  of  cicatricial  strictures  of  the  bowel  with  a 
constricting  peritonitis  is  well  known,  and  is  illustrated 
by  a  vast  number  of  recorded  cases  and  nmseum  speci- 
mens.     A    specimen    in    Guy's    Hospital    aflbrds    a    good 

*  Loc.  cit.,  p.  632. 

t  London  Hospitul  Museum,  No.  Ae.  84. 


OBSTRUCTION   BY   ADHESIOXS. 


80 


exaiujjle    of  a   constriction    at    the   splenic    flexure    due    to 
adhesions.* 

In    a    singular    specimen     from    the    Royal    College    ot 


Fig.  29. — Stenosis  of  ascending  Colon  from  the  contraction  of  Peritoneal 
Adhesions. 


Surgeons  Museum,  one  of  the  appendices  epiploicfe  has 
contracted  such  an  adhesion  to  the  attached  omentum  as 
to  cause  constriction  of  the  bowel t  (i'ig-  -o). 

*  Guy's  Hosp.  Museum,  Xo.  1S')2. 

t  itoyal  Coll.  of  Surgeons  Museum,  No.  2693. 


90 


MORBID   ANATOMY. 


I  have  found  no  example  of  this  form  of  obstruction  in 
the  small  intestine  in  which  there  has  not  been  some  com- 
plication. The  affected  bowel  is  always  adherent  to  the 
parietes  or  to  the  pelvic  viscera.     In  two  cases  reported  by 

Dr.  Fagge  (in  one  of  which 
the  ileum  was  involved 
and  in  the  other  the  jeju- 
aum)  adhesions  existed 
elsewhere,  and  the  final 
obstruction  was  compli- 
cated by  angular  bending 
of  the  intestine  about  the 
point  of  its  attachment.* 
Mr.  Gay  has  reported  a 
case  where  eight  inches  of 
the  ileum  were  adherent 
to  the  fundus  of  a  cancer- 
ous uterus.  The  intestine  so 
involved  was  so  narrowed 
as  barely  to  admit  a  goose- 
quill,  f  It  is  doubtful  if 
this  case  would  fall  under 
the  present  category. 

Fig.  30  shows  a  broad 
membranous  band  passing 
from  the  sigmoid  meso- 
colon to  the  bowel.  Al- 
though the  colon  does  not 
appear  to  have  been  com- 
pressed, the  band  may  have 
hindered  the  progress  of 
the  intestinal  contents. 
As  regards  the  symptoms  incident  to  this  variety  of  ob- 
struction, it  can  only  be  said  that  they  more  or  less  completely 
resemble  those  due  to  stricture  of  the  bowel.  In  the  case  of 
the  colon  this  assertion  may  be  made  without  reservation. 
In  the  case  of  the  small  intestine  the  manifestations  of  the 
disease  appear  to  exhibit  a  more  rapid  development  than  is 
usual  in  stricture,  the  permanent  stenosis  being  complicated 
by  the  effects  of  angular  bending. 

5.  Obstruction  by  the  Matting  together  of  Intestinal 
Coils. — The  many  cases  that  can  be  classed  under  this 
category  present  a  protean  aspect. 

A.  The  Small  Intestine. — The  coils  of  the  lesser  bowel 

*  Loc.  cit. 

t  Path.  Soc.  Trans.,  vol.  iii.,  p.  108. 


Fig.  30. — Sigmoid  Flexure  showing  a  broad 
membranous  Peritoneal  Band  passing 
from  the  Mesocolon  to  the  Gut. 

Tlic  peritoneum  is  white  and  thick.     (Royal  Coll. 
of  Surg.  Mus.,  Ko.    2696  a.) 


OBSTRUCTION   BY  ADHESIONS.  91 

may  be  matted  together  in  many  diiferent  ways.  (1)  In  one 
set  of  cases  a  small  segment  of  the  gut  is  so  adherent  as  to 
form  a  permanent  and  unchanging  loop.  (2)  In  another  set 
of  cases  many  coils,  representing  often  a  considerable  tract  of 
the  intestine,  are  matted  together  so  as  to  form  more  or  less 
complicated  masses.  In  both  instances  the  involved  coils 
are  usually  quite  free  from  adhesions  to  the  parietes  or  to 
other  viscera. 

(1)  In  the  first  set  of  cases  a  simple  permanent  loop  is 
formed  in  the  bowel.  This  loop  may  be  open,  the  walls  of 
the  gut  being  adherent  only  at  the  extremities  of  the  loop 
(Fig.  31,  A  and  Fig.  32),^  or  it  may  be  closed,  the  walls  of  the 
involved  bowel  being  adherent  in  their  entire  extent  (Fig. 
31,  b).  The  latter  variety  involves  a  much  smaller  amount  of 
intestine  than  does  the  former.t  There  are  several  distinct 
conditions  under  which  these  distortions  of  the  bowel  may  be 
produced.  Many  are  the  results  of  hernise.  If  a  coil  of  good 
size  be  involved  in  a  rupture  and  much  compressed  by  the 
hernial  orifice,  adhesions  may  form  at  the  point  compressed, 
and  a  permanent  open  loop  be  formed  after  the  gut  has  been 
reduced.  If  the  herniated  coil  be  small  (a  mere  knuckle),  a 
closed  loop  may  result  from  the  adhesions  produced  by  inflam- 
mation of  the  serous  coat. 

Then  again  an  ulcer  of  the  mucous  membrane  may,  by 
inducing  a  limited  peritonitis,  lead  to  the  formation 
of  a  loop.  If  the  adhesions  are  scanty  and  isolated, 
an  open  loop  is  produced  as  in  Fig.  32 ;  if  exten- 
sive, a  closed  loop  as  in  the  specimen  (No.  Q  128) 
in  St.  Thomas's  Hospital  Museum. 

In  other  cases  the  loop-producing  adhesions  are 
the  result  of  mesenteric  gland  disease,  and  I  have 
seen  two  preparations  where  a  broken-down  or 
caseous  gland  has  occupied  the  angle  formed  by 
the  two  limbs  of  the  loop. 

Sometimes  a  fistulous  passage  connects  the 
cavities  of  the  two  portions  of  bowel  at  the  root 
or  narrow  part  of  the  loop.  Such  a  passage  is 
known  as  a  fistula  bimucosa.  They  most  fre- 
quently result  from  ulcers  of  the  intestine,  but  Fig. 
may  follow  also  from  destructive  processes  induced 
by  compression,  and  from  injury. j 

*  Guy's  Hosp.  Museum  Reports,  1836,  p.  21.,  and  case  in  Brit.  Med.  Jow>i., 
vol.  ii.,  1897,  p.  950. 

t  For  specimens  of  these  loops  see  St.  Bart.'s  Hosp.  Museum,  No.  2100; 
Piith.  Soc.  Trans.,  vol.  x.,  case  by  Mr.  Birkett;  and  St.  Thomas's  Hosp.  Museum, 
Q.  No.  128. 

X  Path.  Soc.  Trans,,  vol.  x.  ;  Mr.  Birkctt's  case. 


92 


MORBID    ANA  TOM  Y. 


One  of  the  most  remarkable  cases  of  fistula  bimucosa  is 
afforded  by  a  report  of  Dr.  Bristowe's  in  the  Pathological 
Society's  Transactions  *  (Fig.  33).  Here  the  transverse  colon 
communicated  with  the  ileum  at  two  points  through  a  cavity 
whose  walls  were  formed  by  firm  adhesions.  The  patient 
died  with  symptoms  of  phthisis  and  dysenteric  diarrhoea,  and 
there  is  little  doubt  but  that  the  primary  mischief  was  caused 

by  a  perforating  ulcer  of  the 
transverse  colon. 

It  does  not  appear  that 
the  open  loop  ever  of  itself 
leads  to  detinite  obstruction. 
In  cases  where  a  fistula 
bimucosa  exists  a  fatal  per- 
foration may  form  in  the 
gut  above  the  seat  of  the 
sinus.  This  may  be  due  to 
fresh  ulceration  of  the  bowel 
formed  independently  of 
any  obstruction  effects.  In 
Mr.  Birkett's  example  of  a 
fistula  bimucosa  following 
a  strangulated  rupture,  a 
like  termination  to  the  case 
ensued,  although  the  cause 
of  the  perforation  in  this 
instance  was  not  evident. 
The  open  loop  may  become 
twisted,  and  so  cause  ob- 
struction, while  it  forms  an 
excellent  point  d'appui 
around  which  a  normal  coil 
may  become  engaged  in  a 
volvulus.  Sir  Astley  Cooper, 
in  his  treatise  on  hernia, 
mentions  a  case  Avhere  "  two 
folds  of  intestine  had  adhered  at  one  point  only  (as  may  be 
represented  by  bringing  the  points  of  the  thumb  and  finger  in 
contact).  Through  the  noose  thus  formed  another  fold  of 
intestine  had  passed,  and  had  become  strangulated." 

The  closed  loop  very  usually  leads  to  obstruction  of 
the  intestine.  Here  the  adherent  bowel  is  so  acutely  bent 
that  a  fold  of  mucous  membrane  projects  into  the  lumen  of 
the  intestine,  and  offers  a  valve-like  impediment  to  the 
passage  of  matters  (Fig.  34,  a).     The  gut  above  the  bend  in 

*  Vol.  xiv.,  1863  p.  201. 


Fio.  32. — Ahdesions   forming  the  Bowel 
into  a  Loop. 

A  probe  is  introduced  into  a  perforation  in 
tlie  intestine. 


OBSTRUCTION   BY   ADTTESIONS. 


9.1 


mucosa,  with  forma- 
tion of  a  Loop  in  the 
Ileum. 


time  enlarges  from  distension  until  it  forms  an  actual  ampulla 
(Fig-.  34,  b)  and  so  renders  the  passage  of  the  contents  of  the 
bowel  still  more  difficult.  A  remarkable  case  fully  reported 
by  M.  Nicaise"^  affords  an  example  ot"  this, 
and  from  his  case  Fig.  34,  b  is  taken.  In 
this  case  the  ampulla  was  so  large  that 
the  lower  segment  of  the  bowel  appeared 
to  issue  from  the  side  of  it  rather  than 
from  the  end.  The  parts  are  compared 
by  M.  Xicaise  to  the  crecum  and  the 
entering  ileum.  The  aperture  was  valve- 
like, and  just  admitted  the  tip  of  the 
index  finger.  The  patient,  a  man  aged 
twenty-five,  had  been  operated  upon  for  a 
strangulated  inguinal  hernia  five  years  Fig.  33.  —  Fist^uk  u 
before  the  fatal  obstruction  came  on.  "'^  '' 

The  symptoms  in  these  cases  may  be 
classed    with    those    that    depend    upon 
stricture  of  the  lesser  bowel,  although  they  are  perhaps  liable 
to  more  acute  modes  of  termination.t     In  M.  Nicaise's  case 
the  patient   had   been   troubled   during   the  five  years  that 
followed  the   reduction  of  his  hernia 
with  attacks  of  colic,  with  occasional 
vomiting  and  with  diarrhoea,  alternat- 
ing  with   constipation.      Eight    days 
before    the    man's    death,   which   oc- 
curred  shortly   after    an    enterotomy 
had   been   performed,   he    was    seized 
with   somewhat   acute   symptoms   as- 
sociated   with    much    vomiting,    with 
occasional   action   of  the  bowels,  but 
with   no    abdominal    tenderness,   and 
with  little  pain.     The  movements   of 
the  intestinal  coils  were  visible  through 
the    parietes.      The    fatal    issue   had 

probably  been  provoked  by  the  administration  of  ])ur- 
gative  medicines  which  had  hurried  much  intestinal 
matter  into  the  ampulla  and  so  produced  the  ob- 
struction. 

Apropos  of  these  cases,  one  might  notice  an  instance  of 
obstruction  of  the  lesser  bowel  by  a  large  gall  stone  where 
the  gut  at  the  obstructed  point  was  bent  upon  itself  and  the 


Fig.  34. 


*   Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  tome  vi.,  18S0,  p.  282. 

t  M.  Bricheteau  (Bull,  de  la  Soc.  Anat.  de  Paris,  1862,  p.  2.57)  reports  a 
case  of  occlusion  by  a  closed  loop,  Ihe  exact  cause  of  which  is  obscure,  where 
the  patient  died  with  acute  symptoms  in  twelve  days. 


94  MORBID    ANATOMY. 

bend  retained  in  a  fixed  position  by  adhesions,  apparently  of 
recent  formation."^ 

(2)  In  tlie  second  set  of  cases,  alluded  to  at  the  commence- 
ment of  this  section  (page  91),  certain  coils  of  the  intestine 
are  found  matted  together  in  a  confused  mass.  The  con- 
dition is  similar  to  that  met  with  in  some  cases  of  chronic 
tuberculous  peritonitis.  Certain  of  the  examples  are  without 
doubt  due  to  tuberculous  peritonitis  of  a  limited  extent.  The 
tubercular  affection  in  most  instances  involves  the  whole 
mass  of  the  intestines  and  is  a  very  diffused  process.  In  the 
present  set  of  cases  the  peritonitis  (no  matter  what  its  cause) 
is  local,  and  only  a  portion  of  the  lesser  bowel  is  involved. 
The  adherent  coils  usually  form  a  roundish  mass,  which  may 
be  almost  as  distinct  as  a  tumour,  and  which  compares  con- 
spicuously with  the  uninvolved  and  normal  bowel.  The 
matted  intestine  may  be  adherent  to  the  parietes,  or  it  may 
be  quite  free.  Sometimes  the  matting  is  brought  about  by 
a  multitude  of  isolated  adhesions.  In  other  cases  the  coils 
are  enveloped  in  fine  membranous  adhesions,  so  that  they 
may  appear  as  if  enclosed  in  a  bag  of  tough  tissue  paper.  An 
example  of  this  latter  condition  is  afforded  by  Fig.  35.  Some 
of  the  coils  in  the  mass  may  be  of  normal  lumen,  others 
may  be  dilated,  and  many  may  be  compressed.  They  are 
commonly  strangely  distorted.  When  obstruction  has  been 
caused,  the  bowel  entering  the  mass  will  be  found  dilated, 
while  that  leaving  it  will  be  more  or  less  shrunken.  The 
amount  of  gut  implicated  varies.  It  may  be  but  a  few 
inches,  as  in  a  case  reported  by  M.  Julliard,  where  six  inches 
only  were  involved,t  or  it  may  be  several  feet,  as  in  an 
instance  recorded  by  Dr.  Bristowe,  where  nearly  one  half  of 
the  ileum  was  found  matted  into  a  confused  mass.J  In 
several  instances  a  part  of  the  colon  has  been  involved  in 
the  adhesions,  as  was  the  case  in  a  specimen  described  by 
Mr.  Sydney  Jones,  where  the  coils  of  the  lower  ileum  were 
not  only  matted  together  but  were  adherent  also  to  the 
caecum.  § 

I  have  met  with  an  instance  in  a  young  woman  where, 
as  a  result  of  mischief  in  the  appendix,  many  feet  of  the 
lower  ileum  became  matted  together  in  inextricable  con- 
fusion. The  adhesions  were  membranous,  were  bright,  thin 
and   translucent,  and  quite   like  the  normal   peritoneum  of 

*  Dr.  Van  der  Byl ;  Path.  Soc.  Trans.,  vol.  viii.,  p.  231.  An  almost 
precisely  similar  case,  minus  the  adhesions,  is  reported  by  Dr.  Draper,  Aew 
I'ork  Medical  Journal,  1882,  p.  17. 

+  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  tome  v.,  1872,  p.  627. 

t  Path.  Soc.  Trans. ,  vol.  viii.,  p.  200. 

§   La>wet,  vol.  i.,  1888,  p.  818. 


OBSTRUCTION    BY    ADHESIONS. 


95 


an  infant.  The  patient  was  liable  to  obstructive  attacks 
of  short  duration,  which  were  marked  by  severe  pain, 
vomiting  and  constipation.  There  was  no  rise  of  tempera- 
ture and  no  marked  tenderness  of  the  abdomen. 

Various  forms  of  local  peritonitis  have  led  to  this  con- 
dition of  the  bowels.  It  has  followed  upon  the  relief  of 
strangulated  hernia,  and  upon  ovariotomy  and  other  ab- 
dominal operations.  It  has  been  due  to  pelvic  peritonitis,  to 
extensive  ulceration  of  the  bowel,  and  to  mischief  in  the 
appendix.     In  one  case  under  my  care  a  clump  of  intestine 


Fig.  35. — Diffused  Peritoneal  Adhesions. 


was  matted  together  in  the  pelvis  and  formed  a  confused 
mass.  The  patient,  a  middle-aged  woman,  had  suffered 
from  a  dermoid  cyst  of  the  ovary  which  had  suppurated  and 
had — after  years  of  suffering — discharged  all  its  contents 
through  the  vagina  and  then  healed. 

In  another  case  of  subacute  obstruction  in  a  young 
married  woman  a  lump  as  large  as  the  fist  could  be  felt 
in  the  abdomen.  This  was  the  seat  of  much  pain  and 
tenderness.  It  was  the  seat  also  of  much  visible  intestinal 
movement  and  of  many  bubbling  and  gargling  noises.  It 
could  also  be  moved  a  little  from  its  place.  A  retro- 
peritoneal hernia  had  been  suggested,  but  the  mass  felt  too 
solid,  and  was,  moreover,  usually  dull  on  percussion.  Occa- 
sionally it  was  resonant  when  percussed.  The  patient  was 
thin,  but  free  from  any  apparent  disease.  The  trouble  in 
her  abdomen  was  almost  incessant,  and  had  persisted  for 
some  weeks.  The  main  complaint  was  of  cohc,  of  griping 
pain  after  food,  of  constipation,  and  of  fi-equent  and  fairly 


m  MORBID    ANATOMY. 

copious  vomiting.  I  performed  laparatoray,  and  found 
some  coils  of  small  intestine  rolled  up  in  a  mass  around 
a  clump  of  tuberculous  mesenteric  glands.  The  bowel 
was  rectified  as  regards  its  position  by  enucleating  the 
glands. 

In  one  recorded  case,  at  least,  the  intestines  were  found 
matted  together  by  peritoneal  inflammation  following  upon 
cancer  of  the  bowel  itself^ 

The  syrixptoms  that  arise  are  practically  identical  with 
those  associated  with  stricture  of  the  small  intestine.  The 
onset  is  gradual,  the  progress  of  the  malady  is  irregular, 
severe  periodic  attacks  are  common,  and  an  acute  termina- 
tion to  the  case  is  not  unusual.  Constipation  is  partial, 
and  often  alternates  with  a  copious  diarrhoea.  The  vomiting 
is  usually  slight,  irregular  in  occurrence,  and  uncertain  in 
duration.  During  an  exacerbation  of  the  symptoms,  and 
especially  during  a  final  acute  attack,  it  may  become 
stercoraceous.  In  one  case  there  was  constant  stercoraceous 
vomiting  for  fourteen  days  before  death.  The  pain,  such 
as  it  is,  is  paroxysmal,  the  intervals  between  the  paroxj'sms 
decreasing  as  the  case  advances.  Early  in  the  case  there 
may  be  an  attack  of  colicky  pain  not  more  frequently  than 
once  or  twice  a  week.  Towards  its  termination  the  paroxysms 
may  come  on  at  intervals  of  a  few  minutes.  The  patient 
usually  emaciates,  and  the  movements  of  the  distended  and 
hypertrophied  coils  of  intestine  above  the  obstruction  are, 
as  a  rule,  evident  through  the  parietes.  There  is  little  or 
no  distension  of  the  abdomen  unless  an  acute  form  of  obstruc- 
tion supervene,  and  even  in  such  a  case  the  meteorism  is 
usually  by  no  means  excessive.  In  two  or  three  instances 
the  mass  of  adherent  bowel  has  been  detected  through  the 
abdominal  parietes  as  an  ill-defined  tumour.  That  the 
tumour,  however,  may  be  sometimes  very  distinct  is  shown 
by  a  remarkable  case  reported  by  Dr.  Fleetwood  Churchill 
in  his  work  on  the  "Diseases  of  Women."  The  patient  in 
this  instance  was  a  woman,  aged  twenty-three,  who  had  a 
tumour  in  the  lower  part  of  the  abdomen  on  the  left  side, 
which  was  dull  on  percussion.  It  was  diagnosed  to  be  an 
ovarian  growth.  She  had  never  had  any  intestinal  symptoms. 
The  abdomen  was  opened  by  an  operation  intended  to  be  an 
ovariotomy,  but  the  tumour  was  found  to  be  composed  of 
many  coils  of  intestine  matted  together  by  old  adhesions. 
The  wound  was  closed,  and  the  patient  recovered. 

This  form  of  obstruction  seems  to  be  as  common  in  men 
as  in  women. 

*  Bull,  de  la  Soc.  Anat.,  1877,  p.  473,  M.  llegeard. 


OBSTRUCTIOX   BY   J  DEE  SIGNS.  97 

The  duration  of  the  cases  when  once  symptoms  have 
appeared  varies,  and  may  be  reckoned  in  months  rather 
than  in  weeks.  In  one  case  intestinal  symptoms  were 
present  for  four  years  before  a  final  and  acute  attack  came 
on  which  ended  in  death.  During  the  four  years  the  patient 
had  been  liable  to  colicky  pains,  and  to  an  obstinate  con- 
stipation, which  at  the  end  of  two  years  changed  to  an  equally 
obstinate  diarrhoea.  In  other  instances  symptoms  resembling 
those  due  to  stricture  of  the  lesser  bowel  had  existed  for 
two,  three,  four,  and  six  months  respectively.  Symptoms 
may  make  their  appearance  very  soon  atter  the  causative 
peritonitis.  In  one  case,  reported  by  Dr.  Fagge,  the  patient 
died  with  symptoms  of  obstruction  which  had  continued  for 
twelve  days  after  the  relief  of  a  strangulated  hernia  by 
operation.  Here  coils  of  gut  were  found  matted  together 
by  adhesions  which  had  formed  since  the  operatioiL 

As  Dr.  Churchill's  case  shows,  even  an  extensive  mattino- 
together  of  intestinal  coils  need  not  be  attended  by  any 
evidences  of  intestinal  disturbance.  Quite  recently,  at  the 
London  Hospital,  I  opened  the  abdomen  of  a  middle-aged 
man  who  had  presented  for  months  the  symptoms  of  pyloric 
obstruction.  I  found  the  whole  of  the  upper  segment  of  the 
abdomen  occupied  by  a  confused  mass  of  adhesions.  Stomach, 
liver,  transverse  colon,  omentum,  and  small  intestine  were 
matted  together  in  the  most  remarkable  way.  The  adhesions 
were  membranous,  were  perfectly  clear,  thin  and  translucent, 
and  reminded  me,  as  other  cases  have,  of  the  normal  peri- 
toneum of  an  infant.  They  were  not  like  the  usual  adhesions 
left  by  peritonitis.  The  most  careful  inquiry  into  the 
patient's  history,  supplemented  by  a  later  inquiry  from  his 
mother,  threw  no  light  upon  the  cause  of  these  adhesions. 
He  had  never  had  any  symptoms  of  peritonitis,  and,  indeed, 
he  had  presented  no  abdominal  trouble  until  the  gastric 
symptoms  appeared. 

This  case,  and  one  or  two  others  like  it,  seem  to  support 
the  possibility  of  intra-uterine  peritonitis. 

The  interest  of  the  case,  so  far  as  the  present  subject  is 
concerned,  rests  in  the  fact  that  in  spite  of  the  mass  of 
adhesions  which  existed  among  the  coils  of  intestme  the 
patient  had  never  had  colic,  constipation,  or  any  intestinal 
uneasiness. 

The  stomach  was  dilated  and  the  pylorus  normal,  but  the 
commencement  of  the  duodenum  was  bent  by  these  adhesions. 
I  separated  the  attachments  about  the  pylorus  so  far  as  I  was 
able.  The  patient  was  relieved  of  his  symptoms  for  only  a 
month  or  so.    As  his  condition  became  in  time  as  bad  as  ever,  I 

H 


98 


MORBID   ANATOMY. 


opened  the  abdomen  a  second  time  and  performed  a  gastro- 
enterostomy. Since  this  measure  the  patient  has  been  quite 
well.  The  adhesions,  as  exposed  at  the  second  operation, 
]3resented  the  same  aspect  as  before  and  rendered  the  approxi- 
mation of  the  jejunum  to  the  stomach  uncommonly  difficult. 

The  pylorus  Avas  examined  from  the  interior  of  the 
stomach  and  was  found  to  be  normal. 

B.  The  Large  Intestine. — The  colon  being  a  more  or  less 
fixed  part  of  the  bowel,  it  follows  that  it  is  not  susceptible  to 
quite  the  same  morbid  conditions  as  have  just  been  described 

as  frequent  in  the  lesser  bowel.     As 

a  result,  however,  of  distension,  parts 

of   the    colon    may  become  greatly 

I  1     W  1 1      elongated,  and  the   abdominal   coils 

I         11         (A        j)      thus    formed    may   become    matted 

^       C  i       C,       together  by  adhesions.     The  effects 

of  colic  distension  are  often  well  seen 
in  the  bowel  above  the  seat  of  a 
chronic  obstruction. 

I  can  find  no  case  where  the 
descending  colon,  the  most  fixed 
part  of  this  bowel,  is  stated  to  have 
altered  its  position  to  any  conspic- 
uous extent  as  the  result  of  disten- 
sion."^ In  one  instance  a  dilated 
ascending  colon  appears  to  have  become  so  curved  that 
its  convexity  was  found  to  be  adherent  to  the  ovary. t 
The  sigmoid  flexure  when  distended  is  apt  to  stretch  to- 
wards the  right  iliac  region,  and  then  to  mount  up  into  the 
right  hypochondriac  region.  The  two  hmbs  of  the  dilated 
loop  may  be  found  matted  together,  or  the  sunmiit  of  the  loop 
may  be  found  adherent  to  the  caecum,  to  the  peritoneum  in 
the  right  iliac  or  hypochondriac  regions,  or  even  to  the  under 
surface  of  the  liver.  The  transverse  colon  undergoes  a 
peculiar  and  common  change  when  much  distended.  Its 
central  point  tends  to  pass  downwards  towards  the  pelvis, 
so  as  to  produce  a  V  or  U-shaped  bend  (Fig.  36,  b).  This 
particular  change  is  quite  frequent  in  the  subjects  of  chronic 
constipation.  The  apex  of  the  V  or  the  bend  of  the  U  may 
become  adherent  to  the  mesentery,  or  to  the  peritoneum  about 
the  pelvis,  or  to  a  pelvic  viscus,  such  as  the  fundus  of  the 


Fig.  36. 


*  Mr.  Curling  reports  a  case  of  stricture  of  the  rectum  where  the 
*'  descending  colon "  is  said  to  have  been  coiled  upon  itself,  ami  to  have 
reached  the  right  iliac  fossa  ;  but  the  gut  in  question  ai)pears  to  have  been  rather 
an  imiuense  sigmoid  flexure  (Path.  Soc.  Trans.,  vol.  x.,  p.  157). 

t  Duchaussoy  ;   Jlem.  sur  I'Anat.  path,  des  Etrang.  internes,  18C0. 


OBSTRUCTION^    BY   ADHESIONS.  99 

ulerus.*  One  limb  of  the  V  may  become  adherent  to  the 
whole  length  of  the  ascending  colon,t  and  so  produce  a 
"double-barrelled  ascending  colon,"  or  the  other  limb  may 
attach  itself  to  the  descending  colon  in  a  like  fashion,  and 
produce  a  similar  appearance  on  the  left  side|  (Fig.  36,  c  and 
D).  In  some  cases  this  deformity  of  the  colon  has  been  the 
result  of  chronic  obstruction  in  the  lower  part  of  the  bowel, 
such  as  a  stricture  of  the  sigmoid  flexure  or  rectum. 

It  is  possible  that  the  V-shaped  bend  may  be  rapidly 
produced.  Thus,  in  a  case  of  volvulus  of  the  sigmoid  flexure 
in  a  woman,  aged  twenty-seven,  which  ended  tatally  in  four 
days,  the  transverse  colon  Avas  found  to  have  descended  in  an 
angular  loop  as  far  as  the  pubes.§  It  is  quite  common  at 
autopsies  to  find  this  angular  bend  in  the  arch  of  the  colon 
without  intestinal  obstruction  of  any  kind  or  at  any  part. 
Such  examples  may  be  the  result  of  chronic  constipation,  and 
so  far  as  my  experience  extends  ai'e  mostly  met  with  in  the 
aged,  in  those  over  sixty  more  often  than  in  those  whose  ages 
fall  between  fifty  and  sixty. 

There  are  cases  where  one  limb  of  the  bent  colic  arch 
is  found  adherent  to  the  ascending  or  descending  colon  for 
its  entire  length,  no  obstruction  of  any  kind  being  found 
in  the  gut  below  the  distorted  segment.  I  am  disposed  to 
believe  that  such  cases  depend  upon  ulceration  of  the  colon. 
The  ulceration  leads  to  peritonitis,  distension  and  distortion 
of  the  transverse  colon  may  follow,  and  then  a  part  of  the 
altered  arch  may  become  adherent  to  the  inflamed  serous 
coat  of  the  ulcerated  bowel.  Thus,  in  the  case  reported  by 
Mr.  Shaw,  the  position  depicted  in  Fig.  36,  c  was  found,  and 
along  the  whole  length  of  the  colon  were  discovered  the 
cicatrices  of  ulcers.  It  is  a  conspicuous  fact  that  in  these 
cases  no  adhesions  are  usually  found  except  between  the 
two  united  segments  of  the  colon.  The  deformity  of  the 
ascending  colon  and  of  the  sigmoid  flexure  above  alluded  to 
is  due  probably  in  all  cases  to  distension  following  obstruction 
lower  down  in  the  bowel. 

Xo  abdominal  symptoms  may  be  excited  by  these  con- 
ditions of  the  colon,  although  there  is  more  usually  some 
evidence  of  simple  chronic  constipation.  The  matting  of  the 
sigmoid  flexure  in  the  way  described  is  apt  to  lead  to  volvulus 
of  that  ]3art ;  and  in  the  case  of  the  deformed  and  adherent 

*  ilr.  Shaw  ;  Path.  Soc.  Trans.,  vol.  iv.,  p.  147. 
t  Dr.  Hillon  Fagge,  loc.  cit. 
J  .Ve  case  of  George  Luff  (p.  100) 

§  Dr.  Fagge,  loc.  cit.  Assuming  that  the  bend  was  not  due  to  chronia 
constipation. 


100  ;  MOEBID    ANATOMY.- 

colic- arch  more  or  less  acute  obstruction  may  supervene  from 
occlusion  by  kinking. 

In  Mr.  Shaw's  case  subacute  symptoms  set  in.  The 
patient,  a  man  aged  sixty- three,  had  had  severe  constipation 
tor  some  three  weeks  before  his  death.  He  obtained  some 
relief  by  aperients,  but  for  the  last  seven  or  eight  days  of  his 
life  the  constipation  had  been  absolute.  He  vomited  ;  his 
abdomen  was  distended  and  tender  and  the  seat  of  colicky 
pain.  He  died  the  day  after  a  right  lumbar  colotomy  had 
been  performed.  The  case  was  complicated  by  the  presence 
of  a  fistula  bimucosa  between  the  ascending  colon  and  the 
jejunum. 

The  following  case  may  be  quoted  as  presenting  several 
points  of  interest : 

George  Luff,  aged  seventy-three,  was  admitted  into  the  London 
Hospital  on  September  lltb,  1882,  with  a  fracture  of  the  femur  and 
a  contusion  over  the  region  of  the  liver,  the  results  of  a  fall.  He  is 
said  to  have  never  had  any  abdominal  troubles  and  to  have  enjoyed 
good  health.  His  bowels  were  regular.'  On  the  14th  he  vomited  a 
little.  On  the  19th  he  developed  some  evidences  of  local  peritonitis 
about  the  seat  of  the  blow.  He  again  vomited  ;  his  bowels  became 
absolutely  confined,  and  his  belly  was  distended  and  tympanitic.  He 
became  rapidly  worse,  the  vomiting  became  incessant,  although  never 
stercoraceous,  the  abdominal  pain  increased,  and  the  patient  died  on 
the  following  day,  the  20th.  The  autopsy  revealed  an  enormous  dis- 
tension of  the  large  intestine  with  a  condition  of  the  transverse  colon 
similar  to  that  shown  in  Fig.  36,  P.  The  descending  part  of  the  colon 
and  one  limb  of  the  distorted  trausverse  colon  were  hrmly  blended  by 
old  adhesions.  The  hepatic  flexure  was  connected  by  dense  fibrous 
bands  to  the  liver  and  gall  bladder,  and  over  this  spot,  which  corre- 
sponded to  the  seat  of  the  injury,  was  a  trifling  amount  of  recent 
peritonitis.  The  rest  of  the  peritoneum  was  quite  normal.  The 
mucous  membrane  of  the  colon  was  unfortunately  not  examined  ;  nor 
was  the  cause  of  the  mischief  about  the  hepatic  flexure  explained.  All 
]):irts  of  the  large  intestine  were  equally  distended,  and  the  rectum 
was  normal.  Here  it  would  appear  that  the  old  man  suffered  no 
inconvenience  from  his  distorted  colon,  whatever  its  cause,  while  his 
health  was  good  ;  but  the  shock  of  the  accident,  his  advanced  age,  and 
above  all,  the  peritoneal  mischiuf  seem  to  have  thrown  the  colon  hors 
de  combat,  to  have  induced  a  paralysis  of  its  walls,  and  a  sudden 
cessation  in  its  functions. 

6.  Narrowing  of  the  Bowel  from  Shrinking  of  the 
Mesentery  after  Inflammation. — It  is  said  that  when  the 
mesentery  has  been  extensively  inflamed  it  may  subsequently 
undergo  such  marked  and  extreme  contraction  as  to  greatly 
narrow  the  bowel  to  which  it  is  attached.  In  such  cases 
the  involved  coils  are  found  bound  down '  to  the  spine 
by  the  shortened  mesentery  and  much  shrunken  in  appear- 
ance.    This  is  often   the  result  of  mesenteric  gland  disease. 


SHBINKING    OF    THE    MESENTERY.  101 

I  might  refer  to  four  apparent  examples,  all  in  young  patients, 
of  this  form  of  contraction.* 

"  We  also  meet,"  says  Leichtenstern,  "  with  an  insidious 
process  of  chronic  peritonitis  in  a  diffuse  form  spread  over 
the  greater  portion  of  the  peritoneum,  especially  of  that 
covering  the  mesentery,  and  then  it  often  presents  a  certain 
independent  character,  and  causes  thickening  and  shortening 
of  the  mesenter}^,  thus  binding  the  convolutions  of  the  small 
intestine  down  to  the  vertebral  column.  This  cirrhosis  of 
the  peritoneum  (peritonitis  deformans,  Klebs)  results  from 
chronic  venous  congestion  in  diseases  of  the  heart,  and  some- 
times exquisite  examples  are  found  with  cirrhosis  of  the 
liver  and  atrophied  nutmeg  liver,  and  also  occasionally  with 
granular  atrophy  of  the  kidneys." t  I  give  this  quotation 
from  Leichtenstern,  as  I  have  no  personal  experience  of 
this  form  of  obstruction,  and  do  not  think  that  the  recorded 
cases  are  so  clear  as  they  might  be. 

The  sy^nptoms  that  arise  in  these  cases  are  practically 
identical  with  those  of  stricture  of  the  small  intestine,  or 
with  those  of  matting  together  of  many  coils  of  the  bowel. 
It  would  appear  from  Dr.  Fagge's  cases  that  the  evidences 
of  obstruction  may  extend  over  years,  e.g.  for  four  years  in 
one  case,  for  two  in  another. 

*  Dr.  Hilton  B'agge  (loc.  cit. )  three  cases ;  and  a  fourth  case  by  the  samf 
physician,  in  Path.  Soc.  Trails.,  vol.  xxvii.,  p.  157. 
t  Loc.  cit.,  p.  632. 


102 


CHAPTER   IV. 

INTERNAL    HERNItE. 

It  will  be  convenient  to  consider  in  this  place  certain  liernise 
which  are  met  with  in  the  abdominal  space,  and  which  are 
called  "  internal "  because  they  form  no  protrusion  outside 
the  body  cavity.  In  these  hernia?  bowel  is  protruded  or 
herniated  through  certain  apertures,  but  those  apertures  do 
not  lead  out  upon  the  surface  of  the  bod}^ 

From  an  anatomical  point  of  view  the  collecting  together 
of  the  rare  and  curious  conditions  which  are  comprised  under 
the  term  "  internal  hernite "  is  convenient,  because  through- 
out a  series  of  cases  apparently  dissimilar  there  is  the 
common  bond  of  a  common  anatomical  state. 

Clinically,  the  cases  which  are  comprised  under  this 
heading  present  many  differences. 

Taken  altogether,  they  form  a  medley  of  symptoms. 
Some  cases  assume  a  chronic  type,  some  an  acute ;  some 
produce  the  phenomena  of  intestinal  obstruction,  some  do 
not ;  in  some  the  clinical  associations  which  surround  the 
term  rupture  or  hernia  seem  fitting  to  the  case,  while  in 
others  the  symptoms  produced  appear  quite  foreign  to  the 
general  circumstances  of  a  hernial  protrusion. 

As  the  conditions  dealt  with  in  this  chapter  are  rare, 
and  as  they  cannot  be  welded  together  by  any  common 
clinical  type,  it  will  be  convenient  to  consider  the  symptoms 
of  each  form  of  hernia  as  it  is  treated  upon,  and  to  leave 
the  ground  free  of  the  encumbrance  of  exceptional  cases. 

Yery  little  examination  into  the  history  of  recordeil  cases 
will  make  it  evident  that  "  internal  hernia "  must  not  be 
confused  with  "  internal  strangulation." 

The  following  varieties  come  under  the  present  heading : 

1.  Diaphragmatic  hernia. 

2.  Hernia  into  the  fo«sa  diiodeno-jejnnalit^. 


-DIAPHRAGMATIC    HERNIA.  103 

3.  Hernia  into  the  Foramen  of  Winslow. 

4.  Intersignioid  hernia. 

5.  Pericsecal  hernia. 

1.  Diaphragmatic  Hernia. — Pathology. — In  this  lesion 
certain  of  the  abdominal  viscera  are  thrust  through  a  hole  or 
rent  in  the  diaphragm  into  the  thorax.  The  aperture  in  the 
diaphragm  may  be  due  to  rupture  by  indirect  violence,  to 
wound,  or  to  congenital  defect. 

The  most  elaborate  account  of  this  hernia  is  given  by 
Lacher,"^  who  deals  with  a  series  of  267  recorded  cases. 
Out  of  Lacher's  cases  150  were  due  to  injur}^,  and  117  were 
of  congenital  origin.  In  both  varieties  the  hernia  is  very 
much  more  common  on  the  left  side.  In  the  first  place 
congenital  gaps  are  more  often  met  with  in  the  left  segment 
of  the  diaphragm,  and  many  suicidal  and  homicidal  wounds 
are  aimed  at  the  heart.  In  the  second  place  the  liver  forms 
a  protection  to  the  right  side  of  the  diaphragm,  and  would 
almost  prevent  a  rupture  should  a  gap  occur  in  that  section 
of  the  septum.  Out  of  the  117  congenital  cases  ninety-eight 
were  left-sided  and  nineteen  were  on  the  right.  Of  the  150 
traumatic  cases  127  were  left  and  twenty-three  were  right. 

The  opening  in  the  diaphragm  is  most  usually  in  the 
posterior  part  of  the  membrane,  and  in  the  tendinous  portion 
of  it. 

In  shape  and  size  it  varies  from  a  mere  slit,  or  small  hole, 
to  a  gap  which,  in  the  congenital  cases,  may  represent  the 
absence  of  one  half  or  more  of  the  diaphragm. 

Very  rarely  has  the  hernia  a  sac.  Out  of  Lacher's  267 
there  was  a  sac  in  only  twenty-eight  examples,  and  of  this 
number  twenty-five  were  congenital.  Jatfet  gives  an  account 
of  twelve  recorded  cases  in  which  there  was  a  sac.  Some 
writers  limit  the  term  '■'  true "  diaphragmatic  hernia  to  the 
cases  in  which  there  is  a  sac. 

With  regard  to  the  contents  of  the  hernia  the  stomach  is 
the  organ  most  frequently  protruded,  and  next  in  frequency 
is  the  colon.  As  a  rule  two  or  more  organs  are  found  in  the 
hernia.  In  only  fifty-three  of  Lacher's  cases  did  the  rupture 
contain  a  single  viscus  only.  The  stomach  was  protruded  in 
151  cases,  the  colon  in  145,  the  lesser  bowel  in  eight}^- three, 
the  liver  in  forty-five,  the  duodenum  in  thirty-five,  the  pan- 
creas in  twenty-seven,  the  c?ecum  in  twent}^,  and  the  kidney 
in  two. 

Clinical  Manifestations. — These  are  subject  to  nnich 
variation.     Many  of  the  recorded  cases  have  occurred  in  still- 

*  Arch,  fiir  klin.  Med.,  1880,  xxvii.,  p.  2G8. 
T  Path.  Soc.  Tmns.,  1894,  p,  224. 


J  04  INTERNAL    HERNIA. 

born  infants,  or  in  infants  that  have  Hved  only  a  few  hours, 
or  a  few  days,  or  weeks.  Several  of  these  infants  have  died 
suddenly.  The  diagnosis  is  always  difficult,  and  indeed  out 
of  267  cases  a  right  diagnosis  was  made  in  only  seven 
instances.  In  a  few  examples  the  hernia  has  given  no 
trouble  and  has  not  been  suspected.  In  the  majority  of 
instances  there  is  distressing  dyspepsia,  with  heartburn, 
thirst,  colic  and  great  abdominal  uneasiness. 

Vomiting  is  common,  as  is  also  palpitation  of  the  heart. 
In  some  cases  the  vomiting  has  been  very  copious,  in  others 
less  copious  but  very  persistent.  Some  patients  have  always 
been  worse  after  exertion,  some  have  had  more  trouble  after 
taking  food,  while  others  have  had  less.  A  foAv  have  had  an 
impression  that  the  food  remained  in  the  chest,  and  many 
have  had  a  severe  fixed  pain  in  the  chest. 

Now  and  then  there  are  alarming  dyspnoea,  great  sense 
of  oppression  in  the  chest,  and  cough.  Some  patients  are 
described  as  having  had  asthma.  The  patient  may  not  be 
able  to  lie  upon  the  affected  side.  This  is  a  common  cir- 
cumstance. 

When  the  hernia  is  large  there  may  be  a  hollowing  of 
the  abdomen  below  the  ribs,  and  a  corresponding  fulness 
of  the  lower  part  of  the  thorax,  together  with  displacement 
of  the  heart  and  evidence  of  the  presence  of  the  stomach 
or  bowel  in  the  thorax. 

The  diaphragm  has  been  found  pushed  up  as  high  as  the 
second  rib,"^  or  even  as  far  nearly  as  the  clavicle.t  Finally, 
the  hernia  may  become  acutely  strangulated,  and  the 
patient  exhibit  all  the  phenomena  of  acute  intestinal 
obstruction. 

Freyt  gives  twenty-one  cases  of  death  from  strangulation 
of  a  diaphragmatic  hernia.  In  each  of  the  cases  the  cause 
of  the  hernia  was  a  wound.  In  seven  the  strangulation 
occurred  very  soon  after  the  injury,  in  fourteen  it  did  not 
appear  until  months  or  years  had  elapsed.  In  some  the 
fatal  strangulation  was  brought  on  by  coughing  or  strain- 
ing ;  in  others  it  occurred  without  reason. 

As  cases  illustrative  of  diaphragmatic  hernia  the  two 
following  may  be  selected,  one  as  an  example  of  a  chronic 
case  and  one  of  an  acute  form. 

The  first  case  is  reported  by  Dr.  Hale  and  Dr.  Good- 
hart  in  the  Transactions  of  the  Clinical  Society  (vol.  xxvi., 
1893,  p.  105). 

*  Udin.  Med.  Joiirn.,  18G9,  p.  894. 
t  Bowditch  :    Diaphragmatic  Hernia. 
X  Wien.  Med.  Wochensch.,  1893,  p.  160. 


DIAPHRAGMATIC    HERNIA.  105 

N.P.,  set.  49,  the  sobject  tii  a  double  inguinal  hernia,  after  much 
exposure  and  hard  M'ork  in  India,  came  to  England  at  the  end  of  1891 
on  account  of  ill-health.  He  complained  chiefly  of  waterbrash  and 
acid  eructations,  with  occasional  vomiting.  He  was  seen  by  Sir  Joseph 
Fayrer,  who  could  detect  no  organic  disease.  When  Dr.  Hale  first 
saw  the  patient,  in  January,  1892,  he  was  lying  in  bed,  and  constantly 
bringing  up  mouthfuls  of  clark-coloured  mucus,  while  about  every  week 
or  ten  days  he  vomited  enormous  quantities  of  fluid  of  a  similar  char- 
acter. He  complained  of  heat  and  pain  at  the  ensiform  cartilage.  His 
bowels  were  obstinately  confined.  His  diet  was  at  first  restricted  to 
milk  and  rusks,  with  only  temporary  relief  ;  he  was  then  given  nothing 
but  peptonised  milk,  and  for  a  whole  month  vomiting  ceased  ;  as,  how- 
ever, it  returned  as  copiously  as  evei',  his  stomach  was  washed  out 
daily  with  decided  benefit  for  about  a  fortnight.  Milk,  farinaceous 
food,  and  eggs  were  then  given  him,  but  coj)ious  vomiting  of  yeasty- 
looking,  foetid  fluid  immediately  resulted.  He  had  been  losing 
flesh  throughout  his  illness,  but  emaciation  now  became  rapid  and 
extreme.  He  M^as  seen  by  Dr.  Goodhart  two  days  before  death. 
Tympanitic  resonance  posteriorly  as  high  as  the  middle  of  the  left 
scapula  and  retraction  of  the  abdomen  were  the  only  abnormal  signs 
observed.     He  was  thought  to  be  dying  of  cancer  of  the  stomach. 

The  post-mortem  revealed  a  diaphragmatic  hernia.  The  hernial 
contents  were  enclosed  in  a  distinct  sac  which  lay  across  the  spine 
immediately  above  the  diaphragm,  and  the  orifice  of  which  extended 
from  the  oesophageal  opening  on  the  left  to  the  opening  of  the  vena 
cava  on  the  right.  The  gap  appeared  to  be  due  to  a  congenital  weaken- 
ing, and  subsequent  bulging,  of  the  midrib  between  the  crura. 

The  sac  contained  two-thirds  of  the  stomach,  and  with  it  a  large 
loop  of  the  transverse  colon,  the  lesser  omentum,  the  greater  part  of 
pancreas,  and  the  duodenum.  The  stomach  was  twisted  somewhat,  so 
that  the  omentum  was  uppermost,  and  the  posterior  wall  of  the  viscus, 
towards  the  pyloric  end,  looked  forwards.  The  pyloric  orifice  was  within 
the  sac,  and  was  unusually  thin.     The  stomach  itself  was  thick. 

The  viscera  except  for  the  displacement  were  normal.  The  pancreas 
was  elongated  from  stretching. 

The  second  case  is  recorded  by  Mr.  A.  E.  Maylard  in  the 
Glasgovj  Medical  Journal  (vol.  xlvi.,  1896,  p.  148). 

A  schoolboy,  aged  eight,  was  seized  with  vomiting  on  Thursday 
night,  October  31st,  1895,  shortly  after  having  eaten  some  nuts  and 
apples.  He  suffered  no  abdominal  pain  at  the  onset.  The  following 
day,  Friday,  he  was  given  some  castor  oil  which  he  vomited.  He  con- 
tinued to  vomit  everything  he  took  on  Saturday  and  Sunday.  On 
Tuesday  evening  his  vomiting  became  "  fiecal."  Neither  flatus  nor 
faeces  passed  during  these  days.  There  was  no  histoiy  of  previous 
disease  of,  or  injury  to,  the  abdomen. 

He  was  admitted  into  the  Victoria  Hospital  at  7.15  p.m.  on  Wed- 
nesday, November  6t\i—i.e.  on  the  sixth  day  of  the  symptoms.  He 
was  then  in  a  condition  of  some  collapse  with  rapid  and  feeble  pulse. 
He  complained  of  pain  and  tenderness  in  the  left  hypochondriac  region. 
The  pain,  he  stated,  commenced  in  the  left  groin,  and  was  spasmodic 
in  character.  The  colon  was  evidently  distended  as  was  the  whole  of 
the  abdomen.  Rectal  examination  revealed  nothing.  Laparotomy  was 
performed  one  hour  after  admission.  Prior  to  opening  the  abdomen 
the   parts   were   palpated,   when    a   very   well-defined,   sausage-sliaped 


106  INTERNAL    HEBNI^. 

tumour  could  be  felt  in  the  epigastric  region,  tapering  off  someAvliat 
towards  the  right  hypochondrium,  but  ending  abruptly  when  traced  to 
the  left.  On  opening  the  abdomen  distended  small  bowel  presented. 
It  led  to  the  ceecum.  This,  with  the  colon  as  far  as  the  splenic  flexure, 
was  enormously  distended.  The  descending  colon  was  collapsed.  On 
examination,  an  aperture  was  found  in  the  diaphragm  through  which 
the  colon  passed.  No  traction  on  the  latter  would  release  the  intestine 
until  the  aperture  w^as  dilated  with  the  finger.  The  gut,  lax  and 
paralysed,  was  withdrawn  and  the  abdomen  closed.  The  boy  survived 
the  operation  twelve  hours.  The  autopsy  showed  a  circular  opening 
three-quarters  of  an  inch  in  diameter  in  the  left  leaf  of  the  diaphragm 
close  to  the  left  lateral  parietes.  Some  omentum  had  passed  through 
the  opening  and  had  become  adherent. 

Treatment. — Operative  measures  are  alone  to  be  con- 
sidered, and  so  far  as  the  present  subject  is  concerned  they 
may  be  regarded  only  as  they  refer  to  cases  attended  with 
all  the  symptoms  of  acute  intestinal  obstruction. 

Many  cases  presenting  these  sjanptoms  have  been  treated 
by  operation,  but  the  results,  so  far  as  I  know,  have  been 
uniformly  unsuccessful  in  the  saving  of  life. 

Schwartz  and  Rochard"^  record  a  case  where  all  the 
typical  signs  of  acute  intestinal  obstruction  were  present. 
Laparotomy  was  periormed,  and  a  careful  examination  of 
the  abdomen  made,  but  nothing  was  detected.  The  patient 
died,  and  the  autopsy  revealed  a  loop  of  bowel  formed  by 
the  transverse  and  descending  colon  strangulated  by  an 
aperture  in  the  diaphragm. 

The  records  of  other  cases  treated  by  operation  show  that 
the  gut  when  reduced  may  be  gangrenous,  or  that  its  re- 
duction may  be  impossible  or  only  attended  by  much  rough 
handling  of  already  damaged  parts. 

There  is  no  doubt  but  that  a  diaphragmatic  hernia  is 
njost  easily  approached  from  the  thorax.  This  has  been 
shown  in  the  treatment  of  recent  cases  depending  upon 
wound.  Postempski  treated  two  cases  with  success  by 
approaching  the  j)rotrusion  through  the  thorax.  In  one  he 
reduced  some  bowel,  in  the  other  he  sutured  and  reduced 
the  w^ounded  stomach.  In  both  cases  he  closed  the  hole 
in  the  diaphragm. 

In  order  to  expose  a  hernia  from  the  pleural  side  an 
extensive  resection  of  ribs  may  be  necessary. 

In  dealing  Avith  a  case  in  which  symptoms  of  intestinal 
obstruction  have  appeared,  it  is  probable  that  the  abdominal 
cavity  will  be  opened  unless  a  A'ery  precise  diagnosis  has 
been  made.  As  soon  as  it  is  discovered  that  the  case  is 
one  of  diaphragmatic  hernia,  the  pleura  should  be  opened. 

*  liccac  do  Chirurgie,  1892,  p.  756. 


HERNIA   INTO   THE  FOSSA   DUODENO-JEJUNALIS.  107 

Such  n,  incasnrc  has  these  advantages.  In  the  first  ph\cc, 
it  enables  the  sni'geon  to  ascertain  the  state  of  the  strangu- 
lated bowel  and  avoid  the  misfortune  of  dragging  a  coil  of 
gangrenous  or  perforated  gut  into  the  abdomen  in  an  in- 
accessible region.  In  the  second  j)lace,  the  opening  into  the 
pleura  permits  of  the  hernia  being  returned  precisely  and 
easily,  and  of  the  more  ready  closure  of  the  hole  in  the 
diaphragm. 

In  one  case  alluded  to  by  Mr.  Stephen  Paget  all  attempts 
to  reduce  the  hernia  through  the  abdomen  failed  until  air 
was  allowed  to  enter  the  pleural  cavity.^  Thirdly,  the  pleural 
cavity,  if  infected,  can  be  treated. 

Against  this  measure  of  opening  the  pleura  it  must  be 
urged  that  the  patient,  in  a  case  of  acute  intestinal  obstruc- 
tion, is  not  in  a  condition  to  stand  an  extended  operation, 
and  that  pneumothorax  is  a  serious  complication  in  a  case 
already  grave  enough. 

2.  Hernia  into  the  Fossa  Duodeno-jejunalis. — Pathology. 
— This  hernia  is  known  by  many  names,  of  which  the 
following  are  the  chief: — Retroperitoneal  hernia,  mesocolic 
or  mesenteric  hernia,  mesogastric  hernia,  intermesenteric 
hernia,  duodenal  hernia,  and  the  hernia  of  Treitz. 

The  fossa  duodeno-jejunalis  is  formed  by  a  fold  of  peri- 
toneum at  the  point  where  the  duodenum  ends  in  the 
jejunum.  It  lies  to  the  left  side  of  this  point,  and  can  be 
exposed  by  drawing  the  transverse  colon  upwards  and 
following  downwards  the  under  layer  of  the  transverse  meso- 
colon. (Fig.  37.)  Its  orifice  looks  upwards,  and  in  well- 
marked  specimens  the  fossa  will  engage  the  thumb  up  to 
the  first  joint.  Out  of  one  hundred  bodies  examined,  I  found 
this  fossa  in  forty-eight.  I  have  given  a  full  account  of  it 
in  Morris's  "  Treatise  on  Anatomy,"  page  1002. 

This  particular  and  remarkable  hernia  has  long  been 
known  to  surgeons.  It  was  originally  supposed  to  represent 
a  curious  deformity  of  the  peritoneum,  and  was  so  described 
by  Neubauer  in  1776.t  Sir  Astley  Cooper  appears  to  have 
been  the  first  to  recognise  that  it  was  a  veritable  hernia. 
He  gives  an  excellent  plate  of  an  example  in  his  great 
work  on  hernia.  The  first  really  complete  account  of  this 
hernia  was  given  by  Trietz,J  and  this  was  supplemented  in 
1868  by  the  excellent  anatomical  descriptions  of  the  peri- 
toneal  fossae    by   Waldeyer.§      The   literary   history    of    the 

*  Surgery  of  the  Chest.     Bristol,  1896,  p.  152. 

t  Opera  Anatomica  Collecta.     Georgius  Hinderer.     Frankfort,  1687. 

%  Hernia  retroperitonealis.     Prag.,  1857. 

§  Plcrnia  retroperitonealis.     Breslau,  1868. 


108 


INTEBNAL    HE11NI2E. 


retroperitoneal  hernia  is  fully  given  by  Jonnesco  in  his  well- 
known  and  exhaustive  treatise."^ 

In  this  hernia  the  fossa  in  question  becomes  deeper  and 
deeper,  and  accommodates  more  and  more  intestine.  The 
entering  gut  pushes  the  peritoneum  which  formed  the  fossa 
in  front  of  it,  and  so  makes  for  itself  a  real  sac.  The  sac 
spreads  in  the  lax  retroperitoneal  tissue,  and  attains  at  last 
enormous  dimensions.  Still,  even  in  the  largest  hernise  there 
is  a  complete  sac,  although  its  substance  may  be  very  thin. 
The  sac  is  behind  the  posterior  parietal  peritoneum,  and  to 


\m%wrmxf(. 


DUODENAL  FOLD 


Fi&.  37.— The  Fossa  Duodeno-jejunalis  (Trevnif). 

expose  the  contents  of  the  sac  from  the  front  two  layers 
of  the  serous  membrane  would  have  to  be  divided :  one 
belonging  to  the  posterior  parietal  peritoneum,  and  one  to 
the  involuted  peritoneum  which  had  extended  in  from  the 
fossa.  The  sac  nearly  always  extends  to  the  left  (left  retro- 
peritoneal hernia).  It  may  in  exceptional  cases  extend  to 
the  right  {right  hernia).  Jonnesco  has  collected  sixty-four 
recorded  examples  of  hernia  into  the  fossa  duodeno-jejunalis, 
and  of  this  number  only  eight  extended  to  the  right,  and 
even  among  these  eight  cases  are  three  which  are  doubtful. 
Our  account,  therefore,  will  concern  itself  with  the  more 
common  type  of  the  hernia.  The  sac  extends  to  the  left 
of  the  spine,  and  the  orifice  of  the  sac  is  just  to  the  left 
of  the  column.  When  the  hernia  is  small  it  forms  a  flattened 
somewhat  kidney-shaped  swelling  beneath  the  paiietal  peri- 
toneum  and    below   the    level    of    the    attachment    of    the 


*  Hernies  Internes  Ketroperitoneales,     Paris,  1890. 


HERNIA   INTO    THE  FOSSA    DFODEXO-JEJUXALIS.   109 

transverse  mesocolon  (Fig.  38).  As  it  extends  it  spreads 
upwards  and  downwards  and  to  the  left,  and  becomes  more 
and  more  globular  in  outline  (Fig.  39). 

The  sac  extends  in  front  of  the  kidney  and  pancreas  and 
the  great  vessels.     Above  it  reaches  up  behind  the  stomach 


Fig.  38. — Small  Hernia  iuto  the  Fossa  Duodeno-jejunalis  {Gncber's  case). 

T  c,   transverse  colon  turned  up ;   j,  jejunum ;    sig,    sigmoid   flexure ;   s,  sac  over  which 
runs  tlie  left  colic  artery;    o,  orifice  of  sac. 

and  below  to  the  pelvic  brim.  The  spleen  is  pushed  in  front 
of  it,  and  to  the  left.  The  omentum  lies  either  in  front  of  it 
or  is  tucked  away  above  its  upper  margin.  The  colon,  as  a 
rule,  retains  to  some  extent  its  normal  position  and  surrounds 
the  hernia  at  the  two  sides  and  above  (Fig.  40).  The  des- 
cending colon  may  be  lost  to  view  behind  the  left  border  of 
the  sac.  The  transverse  colon  may  cross  the  front  of  the  sac 
or  be  found  along  its  lower  border.  In  one  case  reported  by 
Treitz  the  whole  of  the  colon  was  found  to  be  pushed  over 
to  the  riijht  side  of  the  sac. 


no  IXTEBXAL    HERNIA. 

The  sac  contains  more  or  less  of  the  small  intestine, 
according'  to  its  size.  Indeed,  the  amount  of  the  lesser  bowel 
contained  in  the  hernia  may  vary  from  a  few  inches  of  the 
upper  jejunum  to  the  whole  of  the  small  intestine.  The  gut 
enters  the  sac   in    anatomical  order,    the  jejunum   entering 


Yi(i.  39. — Hernia  of  medium  size  into  the  Fossa  Duocleno- Jej unalis  (LainbPs  case). 

o,  great  omeutum  attached  to  transverse  colon  ;  &t,  stomach  ;  j,  jejunum  at  orillce  of  sac  ; 
s,  the  sac ;    c,  ctecuni  ;    sic,  sigmoid  flexure. 

before  the  ileum.  While  the  hernia  is  of  medium  size,  two 
portions  of  bowel  can  be  seen  to  occupy  the  oritice  of  the  sac, 
one  belongs  to  the  entering  and  the  other  to  the  escaping 
bowel  (see  specimen  in  the  nmseum  of  the  Royal  College  of 
Surgeons,  No.  2696  e).  When,  however,  the  hernia  is  com- 
plete, one  coil  only  is  seen,  which  belongs  to  the  termination 
of  the  ileum.  In  a  complete  case,  when  the  abdomen  is  opened, 
of  the  alimentary   canal   only    the   stomach   and   colon   are 


HERNIA  INTO   THE  FOSSA   DUODENO-JEJUNALIS.   Ill 

visible.  The  whole  of  the  small  intestine  is  lost  to  view  in  an 
enormous  sac,  which  is  placed  behind  the  posterior  parietal 
peritoneum,  and  which  seems  to  occupy  the  major  part  of  the 
abdomen. 

The  gut  contained  in  the  sac  is  normal  in  appearance.     If 


£La.  40. — Hernia  in  the  Fossa  Duodeno-Jejunalis  {Treves). 

Tlie   hernial   orifice  is  displacecl  to  near  tlie  Ccecuiii.     The   colon    has   been  drawn   aside   to 
show  tlie  sac  which  contains  all  the  small  intestines. 


strangulation  occurs  it  is  always  produced  by  the  margins  of 
the  orifice  of  the  sac.  As  regards  the  orifice  of  the  sac  its 
site  varies.  When  the  hernia  is  small  it  lies  close  to  the 
vertebral  column  and  to  the  left  of  it.  As  the  hernia  increases 
the  orifice  descends  obliquely  towards  the  right.  It  crosses 
the  spine,  and  may  ultimately  be  found  in  the  right  iliac 
fossa  close  to  the  caecum  (Fig.  40).  The  actual  orifice  is 
either  round,  oval,  or  ellipsoid  in  shape.  In  the  small  hernia 
the  longer  diameter  is  usually  transverse  (Figs.  38  and  39) 
while  in  the  large  hernias  it  is  vertical  (Fig.  40). 


112 


INTERNAL    HEliNI3J. : 


The  size  of  the  orifice  of  the  sac  varies.  The  mean 
measurement  is  two  and  a  half  inches  by  one  inch  and 
a  half. 

Tiie  posterior  margin  of  the  hernial  orifice  is  ill-defined 
and  more  or  less  fixed,  while  the  anterior  margin — which 
Diay  be  considered  to  comprise  thres-fourths  of  the  circum- 
ference of  the  orifice — is  free  and  very  well  marked  (Figs.  39 
and  40). 

At  the  anterior  or  free  margin  of  the  orifice  the  peri- 
toneum in  front  of  the  sac 
joins  the  single  layer  of  peri- 
toneum which  forms  the  sac. 

At  the  ]3osterior  or  fixed 
margin  of  the  orifice  the  peri- 
toneum belonging  to  the  sac 
is  continuous  directl}'  with  the 
peritoneum  belonging  to  the 
rest  of  the  abdominal  cavit}^ 
The  two  layers  will  join  in  the 
same  plane. 

The  mesentery  of  the  in- 
testine within  the  sac  is  con- 
tiimous  by  its  two  layers  with 
the  peritoneum  which  actually 
forms  the  sac. 

It  is  important  to  note  the 
relations  of  certain  blood-ves- 
sels to  the  orifice  of  the  sac. 
These  vessels  have  the  following  relations  to  the  anterior  or 
free  margin  of  the  orifice.  Curving  round  the  upper  part  of 
this  border  is  the  inferior  mesenteric  vein.  In  relation  with 
the  anterior  portion  of  this  border  is  the  ascending  branch 
of  the  left  colic  artery  with  its  vein  (Fig.  41).  At  the  lower 
part  of  the  orifice  the  arter}^  and  vein  may  be  separated  by 
the  free  border  itself  The  thickness  and  roundness  of  the 
upper  portion  of  the  free  border  are  due  to  the  large 
inferior  mesenteric  vein  which  it  contains. 

In  the  right  retroperitoneal  hernia  (the  rare  form)  the 
sac  is  found  on  the  right  side  of  the  spinal  column  and  lying 
between  the  liver  and  the  right  iliac  fossa.  Its  general  dis- 
position is  precisely  the  same  as  in  the  variety  of  the  hernia 
just  described.  It  is  surrounded  closely  by  the  colon  on  the 
right  side,  but  on  the  left  side  the  colon  is  more  or  less  free. 

The  orifice  is  to  be  found  at  some  part  of  the  left  side 
of  the  sac.  Running  in  the  anterior  or  free  margin  of  the 
orifice  will  be  found  the  superior  mesenteric  arter}^ 


Fift.  41. — Hernia  into   the   Fossa 
Duocleiio-jejuualis. 

Relation  of  vessels  to  the  nrilice  of  tlie 
sac: — J,  jejunum  occupying  the  orifice 
of  the  sac ;  ii,  the  licniial  sac  ;  c  s  a, 
colica  sinistra  ai'tery ;  ima,  inferior 
mesenteric  artery  {From  Jonnesco). 


HEBNIA   IXTO    TTfE   FOSSA   DrOBENO-.TEJUNALIS.    11;^ 

The  small  intestine  contained  in  the  sac  is  twisted  upon 
itself  in  such  a  way  that  it  is  placed  behind  its  mesenteric 
pedicle.  This  pedicle  is  connected  with  the  anterior  free 
margin  of  the  sac  instead  of  with  the  posterior  fixed  margin, 
as  in  the  left  hernia. 

Clinical  Manifestations. — This  hernia  is  much  more 
common  in  males  than  in  females,  in  the  proportion  of  about 
5  or  4  to  1.  It  has  been  met  with  at  all  ages,  in  the 
newly-born,*  in  an  infant  of  two  months, t  in  children  of 
fourteen,  J  and  in  men  of  sixty.  § 

The  great  majority  of  the  cases,  however,  have  been  met 
with  in  adults  between  twenty-five  and  fifty.  There  are 
very  few  cases  in  young  children,  e.g.  between  the  ages  of 
two  and  ten  years.  With  the  exception  of  a  case  of  Standen- 
mayer's,  reported  by  Jonnesco,  I  am  not  aware  that  this 
hernia  has  been  diagnosed  during-  life  or  before  operation. 

Clinically  the  cases  mav  be  divided  into  four  categfories : — 

1.  Cases  discovered  post-mortem. 

2.  Cases  attended  with  continued  digestive  disturbances. 

3.  Cases  associated  with  intestinal   obstruction    of   a    .subacute  or 

chronic  type. 

4.  Cases  in  which  the  Ijernia  is  strangulated. 

(1)  The  cases  in  this  categ(jry  are  the  most  numerous. 
In  not  a  few  instances  the  specimen  was  obtained  from 
the  dissecting-room.  In  a  large  proportion  of  the  examples 
there  is  more  or  less  satisfactory  evidence  to  the  effect  that 
the  individual  when  alive  had  had  no  definite  or  very  notice- 
able abdominal  trouble.  In  certain  of  the  cases  there  is 
positive  evidence  on  this  head,  the  patient  having  been  under 
close  observation  before  death,  and  having  succumbed  to 
some  extra-abdominal  affection. 

(2)  The  spnptoms  in  this  series  of  instances  .show  much 
variation.  There  are  vague  pains  in  the  abdomen  or  actual 
attacks  of  colic,  which  may  appear  some  time  after  taking 
food,  especially  such  as  is  indigestible.  Often  the  cohcky 
pains  are  in  no  way  to  be  accounted  for.  There  is  dyspepsia, 
and  possibly  a  dilated  stomach.  In  some  cases  there  has 
been  much  gastric  catarrh,  and  in  others  enteritis.  Con- 
stipation is  common  or  constipation  alternating  with  diarrhcea. 
The  symptoms  are,  indeed,  those  of  continued  abdominal 
uneasiness.     A  great  sense  of  fulness  in  the  umbilical  region 

*  Ciruher  :    Petersburg  Med.  Zeitachrift.  I.,  1861,  p.  247. 
t  Treitz  :    Hernia  retroperitonealis.     Prag.,  1857. 
X  Hauff  :    Jahrbiicher  der  gesammt.  Med.     Schmidt,  1839. 
§  EppiDger  :    Viertelsjahrsch.  liir  die  prakt.  Heilknnde,  1870,  b.  i.,  p.  127. 
I 


114  INTERNAL    HEBNIJE. 

has  been  a  special  complaint  with  many.  If  the  hernia 
be  small  no  abdominal  swelling  can  be  in  evidence.  In 
the  large  hernias  a  circumscribed  tumour  has  been  described 
which  is  usually  on  the  left  side  of  the  abdomen,  which 
is  fixed,  and  feels  like  a  cyst.  This  tumour  is  more  or  less 
resonant  on  percussion,  and  it  may  be  possible  to  demon- 
strate that  it  is  surrounded  by  the  colon.  It  does  not  move 
on  inspiration.  When  the  abdomen  is  the  seat  of  colicky  pain 
the  tumour  may  appear  to  increase  or  become  altered  in  outline. 

(3)  In  the  third  series  of  cases  the  leading  phenomena 
are  those  of  intestinal  obstruction.  The  onset  of  these 
symptoms  may  be  abrupt  or  they  may  be  preceded  by  such 
indefinite  abdominal  disturbances  as  have  just  been  described. 
Two  admirable  examples  of  this  phase  of  the  hernia  have 
been  described  by  Standenmayer'^  and  by  Strazewskit.  The 
former  concerned  a  boy  of  seven  years,  who  died  after  thirty- 
three  days  of  almost  continuous  distress.  The  latter  case 
was  that  of  a  man  of  fifty-five,  who  died  at  the  end  of  fifty- 
three  days,  during  which  time  he  had  exhibited  the  signs 
of  intermittent  obstruction. 

The  principal  symptoms  are  pain  of  the  nature  of  colic, 
vomiting,  aiid  constipation.  The  progress  of  the  case  is  marked 
by  attacks  of  varying  duration  and  of  varying  frequenc}^ 
The  constipation  may  alternate  with  diarrhoea.  In  the  severer 
attacks  the  vomiting  may  be  excessive,  and  the  patient  almost 
collapsed.  The  attacks  become  more  frequent,  and  at  last 
the  vomiting  and  colic  are  almost  incessant  and  the  consti- 
pation is  absolute. 

A  tumour,  with  the  characters  described  in  a  previous 
section,  may  be  detected.  Large  anastomotic  veins  passing 
between  the  epigastric  and  internal  mammary  vessels  may 
be  visible  upon  the  front  of  the  abdomen. 

There  may  be  haemorrhoids,  due — it  has  been  suggested — 
to  pressure  upon  the  inferior  mesenteric  vein. 

Visible  coils  of  intestine  in  movement  may  be  seen 
through  the  thinned  parietes,  and  gurgling  and  bubbling 
sounds  in  the  abdomen  are  almost  constant. 

(4)  In  the  fourth  series  of  cases  the  symptoms  are  those 
of  acute  intestinal  obstruction,  and  of  that  form  which 
concerns  especially  the  small  intestine.  Some  eight  examples 
of  this  variety  have  been  placed  on  record,  and  in  two  of 
these  a  laparotomy  was  performed,  but  without  avail.;}: 

*  Dissertation  zur  Erlang.  der  Doctor vviirde.     Stutto-arfc,  1886. 

t  .Tourn.  Hebdom.  de  M6d.  et  d'Hygiene,  1888,  p.  682. 

j  Ridge  and  Hilton.  Paper  read  before  the  Himteiian  Society,  Jan.  18th, 
1854.  The  patient  was  a  lad  of  fourteen ;  Quenu,  quoted  by  Jonnesco.  Hernies 
Retroperitoneales,  Paris,  1890.     The  patient  was  a  man  of  about  fifty. 


HERNIA    INTO    THE    FORAMEN    OF    WINSLOW.      115 

In  the  eight  cases  aUuded  to  the  patients  were  all  males 
and,  Avith  two  exceptions,  adults.  The  youngest  patient 
was  foiu'teen  and  the  oldest  tifty.  In  only  one  case  was 
the  jejunum  the  portion  of  bowel  strangulation.  In  the  other 
seven  cases  the  strangulation  involved  the  ileum. 

In  five  of  the  cases  the  onset  was  sudden,  and  appeared 
without  definite  warning.  In  the  remaining  three  instances 
the  acute  attack  was  preceded  by  more  or  less  abdominal 
discomfort. 

In  addition  to  the  usual  symptoms  one  notices  in  reading 
the  account  of  these  cases  that  hiccough  was  often  complained 
of,  that  the  vomiting  was  apt  to  become  stercoraceous,  that  the 
pains  were  mostly  about  the  navel,  and  that  in  two  examples 
a  tumour,  with  the  features  already  described  (page  108),  was 
noticed, 

With  our  present  knowledge  it  is  hardly  to  be  imagined 
that  this  rare  form  of  acute  intestinal  obstruction  could  be 
diagnosed  during  life  or  before  operation. 

One  of  the  eight  patients  lived  for  eighteen  days  after 
the  onset  of  the  attack,  but  of  the  others  one  died  within 
twenty-four  hours,  three  lived  two  days,  one  lived  until 
the  fifth  day  and  two  until  the  sixth.  It  will  be  seen, 
therefore,  that  the  form  of  strangulation  is  verj^  acute. 

Treatment.- — It  need  not  be  pointed  out  that  the  only 
treatment  in  this  form  of  hernia  must  consist  in  an  ab- 
dominal section,  with  liberation  of  the  bowel  and  obliteration 
of  the  sac. 

In  dealing  with  the  orifice  of  the  sac  attention  must  be 
paid  to  the  distribution  of  blood-vessels  in  its  immediate 
vicinity.  The  orifice  can  be  enlarged'  by  cautious  division, 
in  a  downward  direction,  of  the  peritoneum  which  forms  it. 
After  the  bowel  has  been  withdrawn  the  opening  into  the 
sac  can  very  probably  be  closed  by  suturing  the  surfaces 
of  peritoneum,  and  the  sac  itself  can  be  freely  opened  and 
its  walls  so  fixed  back  that  they  cease  to  limit  a  cavity. 

In  both  Hilton's  and  Quenu's  cases  the  strangulated  bowel 
was  relieved  without  difficulty. 

3.  Hernia  into  the  Foramen  of  Winslow. — Pathology. 
— This  variety  of  hernia  is  exceedingly  rare,  as  may  be 
readily  understood.  Under  normal  conditions  the  foramen 
of  Winslow  will  only  admit  one  finger,  or,  at  most,  the  thumb. 
It  is  true  that  its  dimensions  vary,  but  it  is  quite  uncommon 
to  find  foramina  so  large  as  to  admit  two  fingers.  The  fora- 
men is  placed  above  the  intestinal  area,  and  the  nearest 
segment  of  bowel — the  duodenum — is  very  fixed.  It  is 
probable  that  the  hernia  is  favoured  when  the  colon — owing 


ne  INTEBNAL    EEUm^.. 

to  a  defect  in  development — is  free  and  suspended  like  the 
small  intestine  from  a  more  or  less  definite  mesocolon.  This 
condition  existed  in  an  example  of  this  hernia  which  I  have 
placed  on  record.^  The  hernia  enters  the  lesser  sac  of  the 
peritoneum.  The  gut,  if  strFuigulated,  Avill,  as  a  rule,  be 
strangulated  by  the  margin  of  the  foramen.  In  my  case 
the  bowel,  after  entering  the  lesser  sac,  had  forced  its  way 
through  the  anterior  layer  of  the  gastro-hepatic  omentum. 

In  a  case  recorded  by  Blandint  some  part  of  the  herniated 
bowel  had  escaped  from  the  lesser  sac  through  a  rent  in  the 
transverse  mesocolon.  By  the  margin  of  that  rent  the  gut 
was  strangulated. 

The  bowel  found  in  the  hernia  is  sometimes  the  small 
intestine  and  sometimes  the  large. 

In  Blandin's  case  just  alluded  to  nearly  the  whole  of  the 
small  intestine  had  passed  through  the  foramen  of  Winslow. 
Only  that  part  was  strangulated  which  had  escaped  through 
the  rent  in  the  transverse  mesocolon. 

RokitanskyJ  mentions  a  case  in  which  "a  large  part 
of  the  small  intestine  "  was  engaged  in  the  rupture. 

In  a  case  by  Treitz  §  several  coils  of  the  lesser  bowel  were 
involved.  In  Square's  case||  eight  inches  of  the  lower  ileum 
were  found  strangulated  and  gangrenous. 

In  the  example  reported  by  Majoli^  a  loop  of  the  trans- 
verse colon  Avas  found  strangulated  in  the  hernia  and  gan- 
grenous. In  my  case  the  csecmn,  the  whole  of  the  ascending- 
colon,  and  a  part  of  the  transverse  colon  had  passed  through 
the  ibramen  and  had  become  strangulated. 

Clinical  Manifestations. — In  most  of  the  recorded  cases 
the  hernia  has  been  strangulated.  The  phenomena  of  strangu- 
lation may  or  may  not  be  preceded  by  abdominal  symptoms. 

In  Majoli's  case  the  patient  was  a  man  of  forty-four  years,  the 
subject  of  chronic  constipation.  During  the  month  of  June, 
1883,  he  suffered  more  or  less  continuously  with  abdominal 
pains,  with  constipation,  and  with  eructations  of  gas.  He 
lost  his  appetite  and  became  wasted.  On  July  .5th  a  tumour 
was  noticed  in  the  upper  part  of  the  abdomen  between  the 
xiphoid  cartilage  and  the  umbilicus.  The  swelling  was  tense 
and  resonant  on  percussion.  It  exhibited  intestinal  move- 
ments, and  was  the  seat  of  borbor^'gmi.  Its  greater  diameter 
was  transverse.      It  was   a   little   tender   on   pressure.      On 

*  Lancet,  October  13,  1888. 

t  Traite  d'Anatomie  topographique,  2nd  ed.,  1834,  p.  467. 

:;  Handbuch  der  spec.  path.  Anat. ,  Band  iii. ,  p.  218.     Vienna,  1842. 

^  Hernia  retroperitonealis,  18-57,  p.  126. 

ll  Brit.  Med.  Joum.,  vol.  i.,  1886,  p.  1163. 

^  Eivista  clinica  di  Bologna,  1884,  p.  605. 


HERNIA   INTO    THE    FORAMEN    OF    WIN'^LOW.      117 


July  7 til  tlie  vomit iiig  coinnienced,  the  pains  increased,  and 
the  constipation  became  more  and  more  obstinate.  The 
patient  could  take  little  or  no  food.  The  symptoms  were 
now  those  of  intestinal  obstruction.  The  Yoniitini:^  persisted 
and  became  stercoraceous,  the  pains  continued,  the  whole 
abdomen  became  distended,  anct  in  spite  of  aperients  and 
enemata  nothing  passed  the  rectum.  The  man  died  on 
July  16  th. 

The  symptoms  of  intestinal  embarrassment  had,  therefore, 
existed  for  six  weeks,  and  during  the  last  ten  days  of  this 
period  the  symptoms  were  those  of  absolute  obstruction. 
The  post-mortem  showed  that  some  30  cm.  of  the  trans- 
verse colon  had  become  strangulated  by  the  margins  of 
the  foramen  of  Winslow. 

In  Mr.  Square's  case  the  patient  was  a  man  of  twenty- 
three  who  was  seized  with  sudden  and  violent  pain  in  the 
epigastrium  shortly  after  a  very  hearty  meal.  He  presented 
the  symptoms  of  acute  intestinal  obstruction.  The  pain  was 
intense  over  and  about  the  xiphoid  cartilage,  the  epigastrium 
was  tender  and  the 
umbilical  region  of 
the  abdomen  unduly 
prominent.  The 
patient  died  three 
days  and  seventeen 
hours  after  the  com- 
mencement of  the 
attack.  The  post- 
mortem revealed 
eight  inches  of  the 
lower  ileum  strangu- 
lated in  the  foramen 
of  Winslow.  The  gut 
was  2'anorenous. 

In  the  example 
of  this  hernia  which 
came  under  my  care 
the  patient  was  a 
healthy  man  of 
twenty-six.  On  April 
9th,  '1888,  after  a 
heavy  meal,  in  which 
periwinkles  played  a 

conspicuous    part,  he         ^^^    4,._Hernia  into  the  Foramen  of    Winslow 

was       seized       wuh  ,  .     .,     ,  , 

,.,  .  -  Aspect  liresented  ou  opening  the  abdomen. 

cramp-hke    pani    m  (Author'^  case.) 


118 


INTERNAL    HERNIA. 


the  abdomen  above  the  uinbilicus.  The  pain  was  intermittent, 
and  there  was  a  sense  of  "  tightness "  in  the  epigastrium. 
Vomiting  appeared  next  day  and  became  persistent.  The 
abdomen  was  seen  to  be  swollen  and  to  be  especiall}^ 
prominent  in  the  epigastric  region.  On  April  12th  the  bowels 
were  opened  by  an  enema  and  the  symptoms  were  for  a  time 
relieved.  The  pain  and  vomiting  continued.  The  swelling 
of  the  abdomen  increased,  and  on  April  1 6th  the  epigastric 
swelling  was  found  to  be  a  little  dull  on  percussion.  There 
was   no   hiccoughc      From   the   beginning  of  the   illness  to 


Poi'tal  V.  hep. 
art.  bile  duct 


Spleen 
Pancreas 

Kidney  J 


Fig.  43. — Hernia  into  the  Foramen  of  Winslow  {A/ttkor's  case). 
The  diagram  sliows  a  section  of  the  body  at  the  level  of  the  Foramen  of  Winslow. 


the  end  the  patient  kept  the  sitting  posture,  declaring  he  was 
unable  to  lie  down.  The  vomiting  was  never  stercoraceous. 
Tenesmus  had  been  marked  from  the  commencement  of  the 
attack.  The  temperature  was  never  raised.  The  con- 
stipation became  absolute.  What  is  defined  anatomically  as 
the  epigastric  region  was  throughout  prominent  and  tender. 
I  performed  laparotomy  on  April  17th,  i.e.  eight  days  after 
the  onset  of  the  attack.  I  discovered  a  strangulated  hernia  in 
the  foramen  of  Winslow.  All  attempts  to  reduce  the  hernia 
failed.  The  patient  died  six  hours  after  the  operation  was 
completed.  The  autopsy  revealed  such  an  arrangement  of  the 
intestines  as  is  shown  in  Fig.  42.  The  csecum,  the  whole  of 
the  ascending  colon,  part  of  the  transverse  colon,  and  some 
inches  of  the  lower  ileum  had  passed  through  the  foramen  of 
Winslow  and  had  become  strangulated  by  the  margins  of  that 
aperture.  The  cajcuni  had  forced  its  way  through  the  anterior 
layer  of  the  gastro-hepatic  omentum  so  that  the  vermiform 


rXTEESlGJIOin    HERNIA. 


119 


appendix  was  actually  lying  on  the  anterior  aspect  of  the 
lesser  curvature  of  the  stomach  close  to  the  oesopliagus 
(Fig.  43).  The  bowel  was  gangrenous  in  two  places,  and  its 
reduction  could  not  be  effected  until  I  had  cut  the  portal  vein, 
the  hepatic  artery,  and  the  bile  duct.  The  right  segment  of 
the  colon  had  a  very  extensive  mesocolon,  the  existence  of 
which  rendered  the  hernia  possible. 

All  the  recorded  cases  of  which  I  have  any  knowledge 


Fig.  44. — The  Intersigmoid  Fossa  [Jonnescd). 

r,  sigmoid  flexure  drawn  up  ;  m  c,  sigmoid  raesocoloa ;  u,  ureter ;  a  s,  sigmoid  artery ; 
a  e,  external  iliac  artery.    The  fossa  is  just  beneath  the  letters  m  c. 


have  occurred  in  male  subjects  with  one  exception  (Treitz's 
case).  All  the  patients  have  been  adults  between  the  ages  of 
twenty-five  and  forty-four. 

In  the  matter  of  treatment  an  abdominal  section  should 
be  carried  out  and  an  attempt  at  reduction  made.  Should 
this  fail,  as  it  did  in  my  case,  it  is  scarcely  worth  while  to 
establish  an  artificial  anus,  if  at  the  same  time  there  are  left 
in  the  lesser  sac  of  the  peritoneum  some  inches  or  more  of 
gangrenous  bowel. 

4  Intersigmoid  Hernia.  —  Pathology.  —  This  term  is 
applied  to  a  hernia  into  the  intersigmoid  ibssa. 

The  intersigmoid  fossa  is  formed  by  the  layers  of  the  sig- 
moid mesocolon.  It  is  funnel  shaped  and  opens  below  on  the 
left  side  of  the  mesocolon.     It  is  placed  over  the  bifurcation 


120 


IXTEBXAL    HERNIA. 


Fig.  4o. — The  lutersigmoid  Fossa. 

from  a  male  embryo  of  tliiee  months;  b, from 
a  female  embrj'o  of  six  months.  The  relations 
of  the  testis  and  ovary  resjiectivf  ly  are  shown 
(from  Jonnesco). 


of  the  iliac  ve  sels,  and  in  very  intimate  relation  with  it  is 
tiie  sigmoid  artery,  which  Hes  above  it  and  to  the  right. 

The  fossa  extends  upwards  for  some  httle  distance  along 
the  course  of  the  ureter  (Fig.  44).  It  is  commonly  met  with 
in  the  foetus  between  the  third  and  sixth  months  (Fig.  45). 
It  is  not  common  in  the  foetus  at  full  term.  I  found  it  to 
exist  in  fifty-two  instances  out  of  one  hundred  bodies 
which  I  examined.^ 

The  fossa  varies  in  depth  from  one  to  one  mch  and 
a  half     It  will  usually  lodge  the  forefinger  up  to  the  first 

joint,  in  one  case  that 
came  under  my  notice  it 
accommodated  the  entire 
thumb ;  and  in  another 
instance  I  could  introduce 
three  fingers  up  to  the 
joints  between  the  first 
and  second  phalanges. 

The  sac  formed  by  the 
general  distension  of  the 
pouch  may  be  small,  but 
in  one  case  it  was  as  large 
as  an  adult  head,  and  con- 
tained tAvo-thirds  of  the  small  intestine  (Jomini's  case). 
The  sac  extends  in  the  lax  retroperitoneal  connective  tissue. 
The  orifice  of  the  sac  lies  to  the  left  of  the  vertebral 
column  and  at  the  inferior  part  of  the  hernial  tumour 
on  its  left  side.  The  sac  when  small  has  been  found 
to  contain  a  few  inches  of  the  lower  ileum  (Eve's 
case). 

Symptoms. — At  least  four  cases  have  been  recorded:  one  in 
a  woman  of  fifty-seven,t  one  in  a  man  of  sixty-five, J,  one  in  a 
woman  of  sixty-three,  §  and  one  in  a  man  of  fifty-three.  ||  In 
three  of  the  cases  the  sjanptoms  were  those  of  strangulated 
hernia,  and  were  acute  and  rapidly  fatal. 

In  the  case  reported  by  'Exe  a  right  hnnbar  colotomy  was 
performed  by  Mr.  Thomas  Smith  on  the  eighth  day.  The 
patient  died  on  the  tenth  day. 

In  Mr.  Eccles's  case  laparotomy  was  jjerformed  on  the 
fourth  day.    A  piece  of  small  intestine  was  foimd  strangulated 

*  F.  Troves :  Anatomy  of  tlnj  Intestinal  Cannl  in  Man.  London,  188.5, 
p.  65. 

t  De  Haen :  Ratio  medendi  in  nosOLomio  practico.  T.  vi.  Paris,  17(39, 
p.  103. 

j  Jomini  :  lieriie  tnkl.  de  In  Suisse  I'oinaiide,  1882,  p.  302. 

v^  Brit.  Med.  Joinn.,  June  13,  1885,  p.  1195. 

jj   ^Ir.  W.  Ecclcs  ;  St.  Bart.'s  Hosp.  Eeports,  vol.  xxxi. 


PEIIIGA'X'AL    HERNIA. 


121 


and  gangrenous.     It  was  excised,  but  the  man  died  in  twelve 
hours. 

In  De  Haen's  case  there  had  been  a  history  for  some  three 
years  of  a  tumour,  which  occasionally  appeared  in  the  left 
side  of  the  abdomen,  and  which  would  vanish  again,  its 
disappearance  being  once  associated  with  the  escape  of  much 
gas  by  the  rectum.  The  patient  was  seized  with  symptoms 
of    acute   obstruction   and    died    unrelieved   on   the   fourth 

^'^y-  .       .  ... 

The  only  treatment  available  in  these  cases  of  hernia  is  an 
innnediate  laparotomy.  If  the  operation  be  done  in  good 
time,  and  care  be  taken  of  the  vessels  about  the  hernial 
orifice,  the  prognosis  should  be  good. 

5.  Pericsecal  Hernia. — Pathology. — In  the  neighbour- 
hood of  the  cfficum  there  are  certa,in  folds  and  certam  fossa3. 


Fio.  46. — lieo-colic  Fossa  (after  Jonnesco). 

A  V,  vorit'onu  appendix;    M.  a,  uipsentery  of  appendi.\ ;    i,  ileum;    m,  mesentery; 
F,  ileo-colic  fold  ;   a,  artery.     Tlie  director  is  placed  in  the  iloo-colic  foss.-i. 

These  have  attracted  the  attention  of  many  waiters  and  have 
given  rise  to  a  very  copious  literature  and  a  very  confused 
nomenclature.  Dr.  Richard  Berry*  has  attempted  to  lessen 
this  confusion  in  a  little  work  in  which  he  has  brought 
together  the  descriptions  of  various  authors,  and  has  made 
intelligible  the  conflicting  series  of  names.  His  account  is 
lucid  and  apparently  exhaustive. 

*  The  Ca'cal  Folds  and  Fossa^.     Edinburgh,  1897. 


122  INTERNAL    HEBNIJE. 

Without  entering  into  any  details,  the  folds  and  fossse 
may  be  enumerated  as  follows,  and  may  be  illustrated  by  the 
very  excellent  drawings  of  Jonnesco  : — 

1.  The  ileo-colic  fossa,  situated  in  the  angle  between  the 
ileum  and  the  commencement  of  the  ascending  colon,  and 
limited  in  front  by  the  ileo-colic  fold  (Fig.  46). 

2.  The  ileo-ccBcal  fossa,  behind  the  junction  of  the  ileum 
and  caecum.      This   fossa    may    extend   upwards    for   some 


Fig.  47. — Ileo-csecal  Fossa  {from  Jonnesco). 

c,  csecum  ;    i,  ileum;    m,  mesentery;    a  v,  vermifoim  appendix;    m,  mesentery  of 
appendix  ;    r,  ileo-cajcal  lold  covering  in  tlie  ileo-caeoal  fossa. 

distance  behind  the  ascending  colon.  It  is  bounded  by  the 
ileo-ccecal  fold  (Fig.  47). 

3.  The  suhccecal  fossce  are  situated  behind  the  csecum. 
They  are  liable  to  considerable  variation  and  are  often 
absent.  Jonnesco  describes  an  inner  and  an  outer  fossa 
in  this  situation  which  are  bounded  by  two  folds,  the  ex- 
ternal and  internal  parieto-colic  folds  (Fig.  48). 

The  periceecal  hernise  are  of  two  kinds.  In  the  first 
variety  the  hernia  takes  place  in  one  of  the  subcsecal  fossae. 
In  the  second  variety  the  hernia  is  supposed  to  have  been 
formed  in  the  ileo-c£ecal  fossa. 

The  subceecal  or  retrocsecal  hernia  is  the  usual  form, 
and,  indeed,  it  would  appear  that  there  is  but  one  example 
of  the  hernia  into  the  ileo-csecal  fossa  on  record.  The 
ileo-colic  fossa  takes  no  part  in  the  production  of  pericsecal 
hernise. 

Subcsecal  Hernia.  —  Jonnesco  has  collected  eleven 
examples   of  this   hernia,   to  which   he   gives   the  name   of 


PERIGjECAL    lIEBiVIA. 


12J 


retroca^cal  hernia.  The  sac  finds  its  way  behind  the 
ascending  colon,  and  extends  in  the  retroperitoneal  con- 
nective tissue.  The  orifice  of  the  sac  is  below  and  behind  the 
csecuni.  Its  margins  are  generally  well  defined.  The  sac 
varies  in  size,  but  is  for  the  most  part  small.  In  one  case 
reported  by  Parise"^  it  measured  7  cm.  by  3  cm.  In 
other  examples — as  in  a  case  by  Rieux  t — the  sac  was  quite 
small. 

One  example  of  a 
large  sac  is  given  by 
Engel.ij:  In  this  case 
nearly  the  whole  of 
the  small  intestine 
Avas  lodged  in  the 
hernia.  The  orifice  of 
the  sac  was  large.  The 
hernia  seems  to  have 
caused  no  trouble.  It 
Avas  discovered  in  the 
body  of  a  soldier,  aged 
thirty-one,  who  had 
died  of  pneumonia. 

The  contents  of 
the  hernia  have  (ex- 
cept in  Engel's  case) 
alwa3^s  been  derived 
from  the  lower  ileum, 
and  have  been  small 
in  amount. 

In   seven    out    of 
the   eleven  cases  the 
bowel    was    strangu- 
lated,  the   strangidating   agent   being  in  each   instance   the 
margin  of  the  sac  orifice. 

In  the  other  cases  collected  by  Jonnesco  there  was  a 
reducible  hernia,  which  apparently  gave  no  trouble. 

Hernia  into  the  Ileo-caecal  Fossa. — John  Snow§  has 
described  a  case  of  internal  strangulation  which  Jonnesco 
maintains  is  an  example  of  this  hernia. 

The  patient  was  a  woman  twenty-four  years  of  age ;  the 
symptoms  were  those  of  acute  intestinal  obstruction,  and 
she  died  on  the  fourth  day.     A  hernial  sac  was  discovered 


Fig.  48.— Sub-ccecal  Fossaj  {from  Jonnesco). 

c,  c»euin ;  i,  ileum  ;  m,  mesentery  of  ileum — above 
it  is  tlie  vermiform  appendix  and  its  mesentery  ; 
/',  external  parieto-colic  fold  ;  /",  internal  parieto- 
colic  fold— between  the  two  folds  is  the  external 
sub-c«cal  fossa.  To  the  right  of  the  fold  /'  is  the 
internal  sub-csecal  fossa. 


*  Mem.  de  k  Soc.  de  Chir.,  Paris,  1858,  p.  399. 
t  These  de  Paris,  No.  128,  1853. 
%  Wiener  mod.  Wochens.,  Sept.  7,  1861,  p.  671. 
§  London  Med.  Gazette,  1846,  p.  125. 


124  JNTEBNAL    HERNUE. 

in  the  position  of  the  ileo-csecal  fossa.  It  admitted  the 
finger  for  about  two  inches. 

Symptovi.s. — In  some  cases,  as  already  stated,  the  hernia 
gave  no  known  trouble  during  hfe,  and  was  unexpectedly 
discovered  after  death. 

The  majority  of  the  cases  in  which  symptoms  have 
occurred  belong  all  to  one  category.  The  hernia  was  stran- 
gulated, the  onset  of  the  symptoms  was  acute,  and  the 
phenomena  of  obstruction  were  severe.  There  was  no  feature 
in  any  of  the  recorded  cases  which  could  have  assisted  in 
the  forming  of  a  correct  diagnosis.  All  the  examples 
appeared  simply  as  instances  of  acute  strangulation  of  the 
small  intestine  in  the  right  iliac  fossa.  The  average  duration 
of  life  in  the  recorded  cases  was  six  days.  One  patient  died 
in  a  clay,  while  one  lived  twelve  days.  These  represent  the 
extremes. 

Exceptionally,  however,  the  pericsecal  hernia  may  be 
attended  with  the  phenomena  of  subacute  or  chronic 
obstruction. 

This  rare  condition  is  well  illustrated  by  a  case  reported 
by  Dr.  Aschofl'.^ 

The  patient  was  a  woman  aged  forty-eight.  While 
scrubbmg  the  floor  she  was  suddenly  seized  with  severe 
pain  in  the  right  side  of  the  abdomen.  There  was  some 
collapse  and  vomiting.  The  pain  and  vomiting  continued, 
and  were  associated  with,  very  obstinate  constipation.  Some 
relief  was  obtained  by  enemata,  and  later  by  washing- 
out  the  stomach.  The  abdomen  became  distended  and  the 
patient  very  ill  ;  coils  of  intestine  in  movement  were 
visible  in  course  of  time  through  the  jDarietes. 

The  case  was  considered  to  be  one  of  chronic  obstruction 
due  to  stenosis  at  the  splenic  tiexure,  and  as  the  patient 
was  very  cachectic  it  was  surmised  that  the  stricture  was 
malignant.  The  vomiting  became  stercoraceous,  and  on 
the  twenty-first  day  of  the  disease  the  abdomen  was 
opened  in  the  right  iliac  region  with  the  intention  of 
doing  a  right  inguinal  colotomy.  A  large  retrocsecal 
hernia  with  a  considerable  sac  containing  small  intestine 
was  discovered.  It  was  reduced,  and  the  patient  made  a 
good  recovery. 

It  would  appear  that  ])ericaical  hernia  is  much  more 
conmion  in  males  than  in  females,  the  proportion  being 
about  4  to  1.  It  is  met  with  in  adult  life,  the  ages  of 
the  patients  who  suffered  from  this  hernia  ranging  between 
twenty-four  and  forty-eight. 

*  Berliner  Klinik,  Het't.  100,,  OcloLer,  189G. 


T'EBTG.¥J!AL    JJERNTA.  125 

The  treatment  would  consist  of  an  early  laparotomy  and 
the  release  of  the  hernia.  So  far  as  I  am  aware,  the  case 
of  Dr.  Aschoff — reported  above— is  the  only  example  in 
which  a  pericecal  hernia  has  been  successfully  dealt  with 
by  operation. 


12G 


CHAPTER    V. 

VOLVULUS 

Under  the  general  term  "  volvulus "  may  be  mcludea  two 
distinct  methods  of  producing  obstruction.  In  one  the 
bowel  is  so  twisted  about  its  mesenteric  axis,  or  even  in 
rare  cases  upon  its  own  axis,  that  it  becomes  occluded.  In 
the  other  form  two  suitable  coils  of  intestine  are  so  inter- 
twined or  knotted  together  as  to  cause  also  an  obstruction 
in  their  lumina. 

The  subject  may  be  most  conveniently  considered  under 
the  following  heads  : — 

1.  Volvulus  of  the  sigmoid  flexure. 

2.  Volvulus  of  the  ascending  colon  and  caecum. 

3.  Volvulus  of  the  small  intestine. 

1.  Volvulus  of  the  Sigmoid  Flexure. — This  part  of  the 
bowel  may  be  occluded  by  either  of  the  two  methods  just 
named. 

(A)  It  may  be  twisted  upon  its  mesenteric  axis.  (B)  It 
may  be  intertwined  with  a  suitable  coil  of  small  intestine. 

(A)  The  Bowel  is  Twisted  about  its  Mesenteric 
Axis. — This  is  the  most  usual  form  of  volvulus,  and 
may,  indeed,  be  said  to  be  the  only  form  that  is  at  all 
common.  If  ail  the  cases  of  volvulus  of  the  intestine  be 
considered  collectively,  it  will  be  found  that  more  than 
two-thirds  of  the  number  are  instances  of  twist  of  the 
sigmoid  flexure  about  its  mesenteric  axis. 

The  normal  flexure  forms  a  loop  which  is  more  like 
a  capital  omega  than  a  capital  sigma.  The  segments  of 
gut  termed  the  sigmoid  flexure  and  the  first  part  of  the 
rectum  form  together  one  single,  defined  and  undividable 
loop. 

This  loop  begins  where  the  descending  colon  ends,  and 
ends  at  the  commencement  of  the  so-called  second  piece  of 


VOLVULUS    OF    SIGMOID    FLEXUBE. 


12; 


the  rectum,  at  the  spot,  in  fact,  where  the  nieso-rectum 
ceases,  opposite  about  the  third  piece  of  the  sacrum.  This  loop 
when  unfolded  may  well  be  compared  to  the  outline  of  a 
capital  n. 

So  far  as  can  be  defined  the  common  ^pot  at  which 
the  descending  colon  ends  is  the  outer  border  of  the  psoas 
muscle.  The  average  length  of  the  omega  loop  in  the 
adult  is  seventeen  and  a  half  inches.  The  longest  loop 
I  have  met  with  measured  twenty-seven  inches,  and  the 
shortest  six  inches  only.  The  average  length  of  the  sigmoid 
mesocolon  is  one  inch  and  a  half  over  the  psoas,  one  inch 
and  three-quarters  on  the  sacrum,  and  three  and  a  half 
inches   in   its   middle   part.     The  attachment  of  the   meso- 


FiG.  49. — Volvulus  of  the  Sigmoid  Flexure. 


colon  takes  the  following  line: — It  crosses  the  psoas  at  a 
right  angle,  then  makes  a  slight  curve  upwards  so  as  to 
cross  over  the  ihac  vessels  about  their  bifurcation,  and  then 
runs  downwards  to  end  in  the  middle  line  of  the  sacrum 
about  its  third  segment.  The  distance  between  the  ex- 
tremities of  the  omega  loop,  i.e.  the  width  across  the 
narrowest  part  of  the  sigmoid  flexure,  is  about  three  inches. 
A  line  drawn  transversely  across  the  sigmoid  mesocolon  at 
its  widest  part  on  an  average  measures  four  inches."^ 

The  arrangement  of  the  bowel  which  is  favourable  for 
the  production  of  a  volvulus  is  the  following : — The  loop 
must  be  of  considerable  length,  the  mesocolon  must  be 
long  and  very  narrow  at  its  parietal  attachment,  so  that 
the  two  ends  of  the  loop  may  be  brought  as  close 
together  as  possible.  This  condition  is  shown  in  Fig.  49,  A, 
where  it  will  be  seen  that  the  loose  and  free  coil  has 
practically  a  fixed  pedicle  around  which  it  could  with  great 
ease  be  twisted. 

This  arrangement  of  the  parts  may  be  congenital,  although 

*  F.  Treves  :    Anatomy  of  the  Intestinal  Canal  in  Man.    London,  1885. 


128  MOB  BID    ANATOMY. 

such  a  circumstance  must  be  most  uncommon,  since  volvulus 
of  the  sigmoid  flexure  is  extremely  rare  in  the  young.  It 
may  be  brought  about,  by  peritoneal  adhesions,  especially 
by  such  adhesions  as  would  tend  to  contract  the  attached 
part  or  root  of  the  sigmoid  mesocolon,  and  so  bring  the 
two  extremities  of  the  loop  together. 

Excessive  length  of  the  omega  loop  is  without  doubt 
a  predisposing  cause  of  volvulus,  as  is  illustrated  by  a 
case  reported  by  Bonuzzi."^" 

The  commonest  cause  of  volvulus,  however,  would  appear 
to  be  chronic  constipation.  In  this  condition  the  loop  is 
more  or  less  constantly  loaded,  and,  above  all,  unequally 
loaded.  Becoming  filled  with  feecal  matters  it  hangs  down 
into  the  pelvis  an  inert  heavy  mass.  So  placed,  it  must 
drag  upon  its  mesocolon,  and  while  the  position  tends  on 
the  one  hand  to  elongate  that  membrane,  it  appears,  on 
the  other,  to  approximate  the  ends  of  the  loop. 

I  have  often  found  the  strait  in  the  sigmoid  mesocolon 
between  the  two  ends  of  the  loop  occupied  by  peritoneum, 
which  is  dense,  opacjue,  and  thickened.  The  peritoneum 
may  appear  to  be  contracted,  and  is  not  infrequenth" 
associated  with  vague,  ill-arranged  adhesions,  which  pass 
from  the  left  leaf  of  the  sigmoid  mesocolon  to  the  parietal 
peritoneum.  What  relations  these  changes  in  the  peri- 
toneum have  to  chronic  constipation  I  am  unable  to  state, 
but  certain  it  is  that  they  are  most  often  met  Avith  in 
elderly  subjects  or  in  those  who  have  been  greatly  troubled 
with  constipation.     (See  Fig.  30). 

It  must  be  remembered  also  that  the  omega  loop  is 
very  muscular,  and  that  it  imclergoes  much  change  in 
dimensions  as  well  as  in  position  when  passing  from  the 
state  of  dilatation  to  that  of  contraction. 

Israel  mentions  a  case  in  which  the  phenomena  of  vol- 
vulus appeared  immediately  after  a  copious  enema  of  water 
had  been  administered. 

When  the  omega  loop  is  in  the  anatomical  condition  above 
described  (and  shown  in  Fig.  49,  a)  it  is  easy  to  understand 
that  a  twisting  of  the  coil  upon  its  mesocolic  axis  may  be 
brought  about.  Some  irregular  movement  in  the  bowel 
may  effect  this,  or  fseces  may  accumulate  in  one  side  of  the 
loop  only  in  such  a  way  that  the  weighted  end  could  fall 
over  the  less  distended  coil.  When  a  heavy  looj)  blocked 
with  fseces  is  concerned,  the  position  of  the  body  may  become 
a  factor  in  the  causation  of  the  twist,  a  circumstance  which 
certain   cases   would   appear   to   illustrate.      The   inert  loop 

*  Annual  of.the  Universal  Mtd.  Sci.,  1893,  vol.  i. 


VOLVULUS    OF   SLGMOTD    FLEXURE.  129 

may  be  rotated  by  movements  in  adjacent  coils  of  small 
intestine,  especially  when  such  segments  of  the  bowel  are 
much  distended  Avith  flatus. 

Certain  cases  of  volvulus  have  been  preceded  b}^  a  con- 
dition of  atony  of  the  bowel  in  some  instances,  and  by 
diarrhoea  in  others.  Lastly,  there  is  no  doubt  but  that  mere 
distension  of  the  sigmoid  flexure  alone  has  great  influence 
both  in  producing  and  maintaining  a  volvulus,  a  fact  to 
which  further  allusion  will  be  made. 

According  to  Potain  there  are  two  kinds  of  twist.  In 
one  the  superior  part  of  the  loop  is  carried  from  above  down- 
Avards,  and  from  behind  forwards,  in  front  of  the  lower  half  of 
the  loop,  so  that  the  end  of  the  descending  colon  is  brought 
into  contact  with  and  in  front  of  the  commencement  of 
the  rectum  ("  type  rectum  en  arriere  "),  Fig.  49,  b.  In  the 
second  form  the  superior  part  of  the  coil  is  carried  from  above 
downwards,  and  from  before  backwards,  behind  the  lower 
segment  of  the  loop,  so  that  the  end  of  the  descending  colon 
is  brought  into  contact  with,  and  behind,  the  commence- 
ment of  the  rectum  ("  type  rectum  en  avant "),  Fig.  49;  c. 

Of  these  two  varieties  the  former  is  by  far  the  more 
common.  The  twist  may  extend  through  an  arc  of  180''  to 
360°,  or  the  bowel  may  be  twisted  twice  or  even  three  times 
about  its  mesocolic  axis.  Since  at  the  root  of  the  flexure 
the  two  ends  of  the  loop  are  nearly  parallel  to  the  mesen- 
terial axis,  it  follows  that  when  the  latter  is  twisted  the 
former  also  must  be  twisted  upon  their  own  axes. 

When  the  volvulus  has  once  formed  it  is  soon  made 
permanent.  The  heavy  and  distended  coil  has  no  power 
of  straightening  itself  Its  ends  being  closed  it  begins  to 
increase  rapidly  m  size  from  distension  with  gas,  and  becomes^ 
moreover  engorged  by  blood  from  pressure  upon  the  vessels 
which  enter  at  the  pedicle  of  the  loop.  The  more  the  bowel 
becomes  distended  the  more  fixed  is  the  volvulus.  In  the 
autopsy  the  twist  may  be  almost  entirely  unrolled  by  main 
force,  but  the  moment  the  hand  is  removed  the  loop  springs 
back  into  its  former  distorted  position.  On  evacuating  the 
gas,  however,  that  distends  the  coil  the  volvulus  can  be 
readily  reduced,  or  may  even  become  reduced  spontaneously. 
In  other  experiments  where  the  volvulus  has  been  reduced, 
it  has  been  made  to  reappear  immediately  upon  distending 
the  bowel  from  above. 

The  unyielding  abdominal  parietes  (anterior)  take  some 
share  in  the  production  of  a  volvulus.  Melchiori  has  demon- 
strated this  by  experiments  made  upon  a  body  that  presented 
a  volvulus.     As  he  inflated  the  now  untwisted  flexure  Avith 


130  MOUBID    ANATOMY. 

air  from  the  colon  it  began  to  form  a  volvulus,  but  as  the 
coil  increased  in  size  and  mounted  up  in  the  abdomen  it 
gradually  unwound  itself  again.  When,  however,  pressure 
was  applied  which  would  correspond  to  that  exercised  by  the 
anterior  abdominal  walls  the  volvulus  was  rendered  per- 
manent."^ In  some  cases  the  volvulus  may  be  held  down  by 
adhesions,  upon  the  division  of  which  it  becomes  readily 
reducible,  t  In  other  instances  a  coil  of  small  intestines  with 
a  long  mesentery  may  be  thrown  across  the  pedicle  of  the 
volvulus,  and  so  help  to  maintain  its  permanency.  J 

In  volvulus  the  occlusion  of  the  bowel  is  brought  about  by 
the  mutual  pressure  which  the  two  ends  of  the  coil  exercise 
upon  one  another.  The  loop  is  therefore  closed  at  both  ex- 
tremities. Cases  have  been  recorded  where  extensive  degrees 
of  volvulus  have  been  associated  with  a  narrowing  of  the 
lumen  of  the  ^ut  of  so  slis^ht  a  character  as  to  cause  no 
symptoms.  Leichtenstern  reports  a  case  where  such  a  con- 
dition was  met  with,  and  where  distension  actually  relieved 
the  volvulus.  The  specimen  was  from  the  body  of  a  boy, 
aged  eleven,  who  had  had  no  intestinal  troubles.  He  pre- 
sented a  chronic  twisting  of  the  flexure,  with  close  approxi- 
mation of  the  ends  of  the  loop.  "  If  air  is  forced  in  from  the 
side  of  the  colon,  the  S  loop  untwists,  and  again  resumes 
its  twisted  position  when  the  air  is  allowed  to  escape,  a 
proceeding  that  must  have  been  repeated  during  life  with 
every  passage  of  faeces." 

At  the  autopsy  in  fatal  cases  the  sigmoid  flexure  is  found 
to  be  enormously  distended.  It  may  seem  to  occupy  the 
whole  abdominal  cavity.  The  rest  of  the  colon  and  the  small 
intestines  lie  behind  it,  and  are  more  or  less  hidden  by  it. 
In  cases  of  slight  distension  the  loop  reaches  about  to  the 
umbilicus.  As  it  becomes  more  distended  it  tends  to  move 
towards  the  right  hypochondriac  region.  It  then  lies  in 
front  of  the  stomach,  and  ultimately  reaches  the  liver.  In 
severe  cases  the  diaphragm  is  much  pressed  upon,  and  may 
be  pushed  up  to  within  16  cm.  {Q\  inches)  of  the  clavicle,  or 
even  up  to  the  level  of  the  third  or  fourth  rib.§  In  one 
instance,  fatal  at  the  end  of  seven  days,  the  diaphragm  had 
been  raised  to  the  level  of  the  third  rib,  the  lung  had 
been  much  compressed,  while  its  lower  parts  were  hepatised 
and  empty  of  air.  || 

*  Quoted  by  M.  Liebaut,  Du  Volvulus  de  I'lliaque  du  Colon.     These  de 
Paris,  1882. 

f  Case  by  Dr.  Atherton  ;  Boston  Med.  and  Surg.  Journ.,  1883,  p.  531, 

X  Cas-e  by  M.  Leger;  Bull,  de  la  ISoc.  Aiiat.  de  Paris,  1875. 

§  Libeant ;  loc.  cit. 

li  Dr.  Esaii ;  Deutsches  Archiv  fiir  clinische  Med.,  b.  xvi.,  1875,  p.  474. 


VOLVULUS    OF   SIGMOID    FLEXURR.  131 

The  twisted  coil  is  more  or  less  intensely  congested.  In 
colour  it  may  present  any  depth  between  a  dark  red 
and  a  black.  Its  walls  are  often  much  thickened  by  in- 
filtration, and  are  softened  and  friable.  The  serous  coat 
is  very  commonly  found  to  exhibit  a  rent  or  even  several 
rents.  These  may  be  extensive,  and  often  involve  the 
muscular  coat  also,  whilst  the  mucous  membrane  escapes. 
I  am  not  aware  that  these  rents  have  ever  led  to  actual 
rupture  of  the  twisted  loop  during  life,  nor  can  I  find  an}'' 
case  where  perforation  of  the  loop  has  occurred  from  ulcera- 
tion of  its  mucous  lining.  If  the  patient  live  long  enough 
and  the  case  be  severe,  the  walls  of  the  flexure  become 
gangrenous.  This  gangrene  is  met  with  in  the  form  of  one 
or  more  patches  which  involve  all  the  coats  of  the  bowel. 

The  twisted  loop  will  be  found  to  contain  much  flatus,  and 
to  be  otherwise  occupied  by  fluid  faecal  matter  mixed  with 
harder  masses.  Sometimes  the  contents  are  entirely  solid, 
and  in  other  instances  entirely  liquid.  Blood,  often  in  con- 
siderable quantity,  may  be  found  mixed  with  these  contents.'^ 
The  twisted  mesocolon  will  be  of  a  violet  or  purple  colour 
and  engorged  with  blood. 

The  rest  of  the  intestines,  and  especially  the  colon,  are 
distended.  The  distension  seems  to  be  only  limited  by  the 
size  of  the  sigmoid  flexure.  In  cases  where  the  involved  loop 
is  of  enormous  size  the  distension  of  the  rest  of  the  intestine 
is  usually  comparatively  slight,  the  gut  actually  lacking  room 
within  which  to  expand.  The  descending  colon  is  often  much 
enlarged  and  congested.  I  And  that  only  twice,  in  twenty 
recorded  cases  that  I  have  collected,  has  perforation  occurred. 
In  one  instance  the  perforation  was  in  the  csecum,  in  the  other 
in  the  bowel  just  above  the  volvulus.  In  one  or  two  instances 
the  mucous  membrane  in  the  lower  part  of  the  descending 
colon  is  described  as  being  rent. 

Peritonitis  is  singularly  constant  in  this  aftection,  It 
develops  early,  commences  upon  the  involved  bowel  and  then 
spreads  over  the  rest  of  the  serous  membrane.  In  seventeen 
of  the  twenty  cases  just  alluded  to  the  state  of  the  peritoneum 
is  described.  In  only  two  cases  out  of  this  number  was  there 
no  peritonitis.  In  one  of  these  examples  the  patient  had 
died  in  forty-eight  hours,  in  the  other  he  died  suddenly  at  the 
onset  of  the  attack.  In  the  remaining  fifteen  cases  there  was 
peritonitis.  In  one  of  these  instances  it  was  still  limited  to 
the  sigmoid  flexure  (the  patient  had  died  on  the  fourth  day). 
In  two  instances,  as  already  mentioned,  there  was  perforation. 

*  In  a  case  by  Dr.  Crisp,  the  coil  contained  a  jjint  of  thick  blood ;  Path. 
Soc.  Trans.,  vol.  xxiii.,  p.  112. 


132  MORBID    ANATOMY. 

The  remaining  cases  were  simple  examples  of  acute  diffused 
peritonitis. 

Ill  many  instances  there  was  much  bloody  fluid  in  the 
peritoneum. 

(B)  The  Bowel  is  Intertwined  with  a  Suitable  Coil  of 
Small  Intestine. — In  these  cases  the  sigmoid  flexure  must 
have  the  anatomical  arrangement  described  in  the  preceding 
paragraph,  i.e.  it  must  form  a  long,  free  loop  with  a  narrow 
pedicle.  The  loop  of  small  intestine  should  possess  also  an 
unnatural  mobility,  and  should  have  an  unduly  long  and 
narrow  niesenteric  pedicle.  In  cases  where  two  such  coils 
have  become  intertwined  it  is  found  that  the  loop  of  the 
lesser  bowel  varies  in  length  from  four  to  twenty-one  inches, 
Avhile  that  of  the  sigmoid  flexure  measures  from  twelve  to 
forty  mches  (Leichtenstern).  The  usual  mode  of  intertwin- 
ing is  as  follows :  The  loop  of  small  intestine  falls  in  front  of, 
or  across,  the  pedicle  of  the  sigmoid  flexure.  The  flexure 
then  winds  itself  around  the  axis  formed  by  the  lesser  coil. 
It  passes  upwards  in  front  of  the  loop  of  small  intestine,  and 
then  moves  backwards  and  downwards  so  that  its  free  end 
passes  behind  the  pedicles  of  the  two  coils.  In  this  way  the 
abnormal  sigmoid  flexure  forms  a  complete  turn  around  the 
coil  of  lesser  intestine.  Both  segments  of  the  bowel  become 
strangulated,  but  the  occlusion  will  be  most  severe  in  the 
axial  loop.  According  to  Leichtenstern,  this  variety  of  inter- 
twining occurs  in  more  than  one  half  of  all  the  cases  belong- 
ing to  this  species  of  volvulus.  Three  other  methods,  however, 
of  intertwining  occur.  In  one  the  loop  of  ileum  lies  in  front 
of  the  pedicle  of  the  sigmoid  loop,  which  in  this  instance 
forms  the  axis.  In  the  remaining  two  cases  the  small  intes- 
tine passes  behind  the  pedicle  of  the  sigmoid  flexure,  when 
the  loop  of  ileum  ma}"  form  the  axis  around  which  the  flexure 
is  entwined. 

In  all  these  examples  strangulation  is  ver}^  severe,  and  is 
marked  by  great  vascular  engorgement  of  the  involved  loops. 
Such  engorgement  is  met  with  in  all  cases  where  an  extensive 
mesenteric  pedicle  is  pressed  upon.  Not  only  are  the  walls  of 
the  engorged  bowel  infiltrated  with  blood,  but  much  hsemor- 
rhage  may  take  place  into  its  cavity,  and  there  is  usually  an 
abundant  sero-sanguineous  exudation  into  the  peritoneal 
cavity. 

Leichtenstern  has  collected  no  less  than  twenty-one 
examples  of  this  form  of  obstruction.  With  one  exception 
only  the  patients  were  all  males.  They  were,  moreover,  all 
adults,  the  ages  ranging  between  twenty-four  and  seventy- 
three. 


VOLVULUS    OF   ASGENDLNG    COLON.  133 

2.  Volvulus  of  the  Ascending  Colon  and  C^cum. — 
Volvulus  occurring  in  this  part  of  the  intestine  may  assume 
a  variety  of  aspects,  and  is,  in  any  case,  apt  to  adopt  a  very 
complicated  arrangement. 

It  may  be  considered  under  three  categories.  (1)  A  twist 
of  the  ascending  colon  around  its  own  axis.  (2)  Twists 
brought  about  by  an  abnormal  loop  formed  by  the  ascending 
colon  and  caecum  with  a  long  and  distinct  meso- 
colon. (3)  Twists  of  the  ciecum  "upon  itself"  or  about  its 
own  axis. 

(1)  Occlusion  of  the  bowel  may  be  brought  about  by  a 
twist  of  the  ascending  colon  around  its  own  vertical  axis.  It 
would  appear  that  this  condition  may  be  found  in  a  colon  that 
presents  no  anatomical  abnormalities.  It  is  extremely  rare. 
I  have  been  able  to  find  but  one  distinct  instance  of  it.  This 
was  in  a  case  reported  by  Mr.  Curling.  The  patient  was  a 
man  aged  twenty-seven,  who  was  attacked  with  symptoms  of 
intestinal  obstruction  which  ended  fatally  in  eight  days."^ 
More  than  one  writer  on  intestinal  occlusions  refers  to  this 
variety  of  volvulus,  but  gives  no  case. 

The  two  other  varieties  of  twist  met  with  in  this  region 
depend,  so  far  as  I  can  ascertain,  upon  certain  congenital 
abnormalities  in  the  bowel  without  which  neither  form  of 
volvulus  could  have  been  possible.  I  have  collected  seven 
cases  of  these  species  of  twist,  and  in  every  instance  there  was 
some  congenital  malformation  of  the  parts  involved.  It  may 
be  here  convenient  to  note  the  character  of  the  malformation 
associated  with  these  cases. 

In  the  foetus  the  small  bowel  occupies  at  one  time  the 
right  side  of  the  abdomen,  while  the  large  gut  is  represented 
by  a  straight  tube  which  passes  on  the  left  side  vertically  from 
the  region  of  the  umbilicus  to  the  pelvis.  The  caecum  is  at 
first  situated  within  the  umbilicus,  and  then  ascends  in  the 
abdomen  towards  the  left  hypochondrium.  It  next  passes 
transversely  to  the  right  hypochondrium,  and  then  descends 
into  the  corresponding  iliac  fossa.  It  may  be  permanently 
arrested  at  any  part  of  its  course.  Thus  the  ciecum  may  be 
found  about  the  umbilicus,  or  in  the  sac  of  a  conafenital 
umbilical  hernia,  or  in  the  left  hypochondriac  region  (the 
ascending  and  transverse  parts  ot  the  colon  being  absent), 
or  it  may  be  found  in  the  right  hypochondrium,  the  ascending 
colon  alone  being  unrepresented.  The  whole  of  the  large 
intestine  has  at  one  time  an  extensive  mesocolon,  and  in. 
some  rare  cases  this  condition  may  persist  throughout  lite. 
This   mesocolon  may  be  as  ample  as  the  noivmal  mesentery 

*  Path.  iSoc.  Trails.,  vol.  iv.,  p.  oil. 


134  MOBBID    ANATOMY. 

and,  when  present,  it  allows  a  remarkable  freedom  of  move- 
ment to  the  colon. 

(2)  The  ascending  colon  and  caecum  when  provided  with 
a  long  mesocolon  are  very  apt  to  get  into  difficulties.  The 
coil  may  become  twisted  about  its  own  mesenterial  axis,  just 
as  is  the  case  with  the  sigmoid  flexure.  An  instance  of  this 
is  recorded  by  Mr.  Avery.  Here  the  distended  ascending 
colon  formed  an  enormous  loop.  The  patient,  a  man  aged 
fifty-five,  died  after  nine  days  of  almost  complete  obstruction.^ 
Left  lumbar  colotomy  had  been  performed,  and  the  portion  of 
gut  opened  was  found  to  be  the  extremity  of  the  loop  formed 
by  the  ascending  colon. 

M^hen  this  part  of  the  large  intestine  is  practically  free, 
and  has  a  large  and  long  mesocolon,  it  may  form  an  axis 
around  which  a  suitable  coil  of  small  intestine  may  be 
entwined,  or,  on  the  other  hand,  it  may  itself  wind  around 
any  loop  of  the  lesser  bowel  that  is  in  a  position  to  be  so 
engaged. 

Mr.  Walsham  reports  a  case  in  a  man  aged  sixty-three 
in  which  "  the  caecum  with  the  beginning  of  the  colon  was 
twisted  three  times  from  right  to  left  around  the  lower 
part  of  the  ileum,  forming  a  corkscrew-like  coil,  the  caecum 
being  situated  at  the  apex."t 

The  symptoms  of  obstruction  were  very  acute.  In  this 
case  the  colon  traced  backwards  from  the  splenic  flexure, 
instead  of  passing  trans versel}^  across  the  abdomen,  descended 
to  the  left  iliac  fossa,  and  thence  turned  upon  itself  and  ra.n 
up  again  to  the  stomach.  From  the  stomach  it  passed  nearly 
vertically  downwards  to  the  ceecum,  which  was  situated  over 
the  last  lumbar  vertebra  and  about  the  middle  line. 

The  arrangement  of  parts  is,  indeed,  precisely  the  same 
as  has  been  described  in  connection  with  the  sigmoid  flexure. 
The  latter  form  of  volvulus,  where  the  large  gut  winds  round 
the  small,  is  the  more  common.  In  one  case  "the  caecum 
was  found  lying  under  the  diaphragm,  close  to  the  spleen, 
the  large  intestine  attached  to  it  having  been  twice  twisted 
round  the  lengthened  mesentery  of  the  small  intestine, 
causing  a  double  obstruction."! 

(8)  In  this  variety  of  volvulus  the  caecum  has  been 
described  either  as  "  bent  upon "  itself  or  as  twisted  upon 

*  Path.  Soc.  Trans.,  vol.  ii.,  p.  222. 

t  Trans.  Clin.  Soc,  Lond.,  1888,  p.  139  ;  and  also  Trans.  Path.  Soc,  Lond., 
1888,  p.  110. 

:{:  Case  by  Mr.  Charles  Firth  ;  Brit.  Med.  Journ.,  vol.  ii.,  1882,  p.  165.  See 
case  by  Dr.  Sands,  where  the  caecum  was  in  the  right  hypochondrium,  and  where 
the  mesentery  and  small  intestine  were  encircled  and  constricted  by  the  meso- 
colon.    JVew  York  Med.  Record,  vol.  xxxi.,  1882,  p.  427. 


VOLVULUS    OF   SMALL    INTESTINE.  135 

itself.  The  difference  between  these  two  very  similar  terms 
is  really  greater  than  perhaps  the  terms  themselves  would 
permit,  in  the  former  instance,  the  csecum  is  bent  about 
a  line  at  right  angles  to  its  long  axis.  The  result  is  that 
the  lower  part  of  the  caput  coH  is  found  in  front  of  the 
ascending  colon,  its  posterior  surface  becomes  anterior,  while 
the  appendix  and  the  lowest  point  of  the  caecum  become 
uppermost.  At  the  angle  of  the  bend  there  is,  of  course, 
a  deep  crease  across  the  bowel,  and  by  the  bending  in  of 
the  mucous  membrane  at  this  crease  the  lumen  of  the  gut 
is  occluded.  Two  good  examples  of  this  volvulus  have  been 
described,  one  by  i)r.  Fagge,^  the  other  by  Dr.  Handheld 
Jones.t 

In  the  other  variety  the  caecum  is  twisted  around  its  own 
long  or  vertical  axis,  so  that  its  relations  to  the  ascending 
colon  are  practically  undisturbed.  Three  examples  of  this 
form  have  been  recorded  by  Dr.  Fagge.t 

In  all  of  these  five  instances  of  volvulus  the  ca3cum 
presented  some  abnormality  which  may  be  safely  regarded 
as  congenital.  In  one  instance  it  was  found  in  the  right 
hypochondrium,  in  another  in  the  left,  in  a  third  example 
it  occupied  the  pelvis,  and  in  a  fourth  it  was  found  to  the 
left  of  the  umbilicus.  In  each  of  these  cases  the  ascending 
colon,  or  the  gut  which  should  represent  it,  presented  a 
corresponding  anomaly,  while  the  mal-placecl  bowel  was 
provided  with  an  extensive  mesocolon.  A  less  definite 
case  of  volvulus  of  the  ctecum  is  reported  by  Mr.  Bryant 
(Clin.  Soc.  Trans.,  1888,  p.  142).  Here,  also,  there  Avas 
"  congenital  freedom  of  the  ceecum  and  ascending  colon." 

These  forms  of  twist  must  be  classed  among  the  least 
conunon  varieties  of  intestinal  obstruction. 

3.  Volvulus  of  the  Small  Intestine. — Twists  of  this 
part  of  the  bowel  may  be  considered  under  two  categories. 
In  one  a  loop  of  the  small  intestine  is  twisted  about  its 
own  mesenteric  axis,  in  the  other  a  suitable  coil  or  loop  of 
the  bowel  is  engaged  in  a  volvulus  Avith  another  suitable  coil. 

(A)  A  Volvulus  of  the  Small  Intestine  about  its  Mesen- 
teric Axis. — Here  a  loop  of  the  bowel  is  twisted  around  an 
axis  represented  by  a  line  passing  along  the  mesentery  from 
its  root  at  the  spine  to  the  intestine.  It  has  abeady  been 
pointed  out  that  this  form  of  twist  is  quite  common  in 
cases   of   strangulation    by   bands   and   through   apertures.  § 

*  Guy's  Hosp.  Reports,  vol.  xiv. 
t  Med.  Times  and  Gazette,  vol.  i.,  1872,  p.  3. 
X  Guy's  Hosp.  Reports,  vol,  xiv. 

§  As  examples,  may  be  quoted  a  case  described  in  the  Brit.  Med.  Jowrn., 
April  24.  1897,  p.  1023,  and  a  case  reported  in  the  Trans.  Ptith.  8oc,  1890,  p.  127. 


136  MOB  BID    ANATOMY. 

Many  instances  of  sucli  strangulation  are  recorded  where 
the  occkision  of  the  involved  bowel  has  been  brought  about 
rather  by  its  having  become  twisted  upon  itself  than  by  its 
being  actually  pressed  upon  by  the  band  or  by  the  margin 
of  the  aperture.  On  relieving  the  volvulus  by  perforating 
the  bowel  the  gut  has  been  found  to  be  so  lightly  held 
that  the  slightest  degree  of  traction  has  served  to  reduce 
it.  These  cases  are  often  associated  with  evidences  of 
incomplete  obstruction,  with  pain  that  is  paroxysmal,  with 
vomiting  that  is  irregular  in  amount  and  intensity,  and  with 
constipation  that  need  not  be  absolute. 

Many  instances  also  may  be  alluded  to  where  ad- 
herent loops  and  coils  ol  the  lesser  bowel  have  become  so 
twisted  upon  themselves  as  to  produce  occlusion,  and  such 
a  circumstance  has  often  given  an  acute  ending  to  a 
chronic  case. 

It  would  appear  that  the  existence  of  a  gall  stone  in  the 
bowel  may  cause  rotation.  Mayo  Robson  reports  two 
examples  of  this  condition."^  From  a  case  reported  by 
Briddonf  it  would  seem  that  a  lipoma  in  the  mesentery  might 
have  the  same  effect.  In  the  present  set  of  cases  the  gut  is 
entirely  free  from  adhesions  and  the  volvulus  entirely 
independent  of  any  constricting  band.  The  condition  of  the 
intestine  which  favours  twisting  is  identical  with  that  which 
predisposes  to  volvulus  of  the  sigmoid  flexure.  A  certain 
part  of  the  bowel  has  an  unduly  long  mesentery  whereby  it 
becomes  to  some  extent  separated  from  the  remainder  of  the 
intestine  The  two  ends  of  the  coil  so  individualised  are 
brought  more  or  less  together,  so  that  a  possible  pedicle  is 
formed,  about  which  the  gut  may  be  twisted.  This  condition 
of  parts  may  be  found  in  a  loop  of  ileum  that  has  long  been 
herniated  and  then  reduced.  The  approximation  of  the  two 
ends  of  a  coil  may  be  brought  about  by  mesenteric  peritonitis 
due  to  glandular  disease  or  to  other  causes.  In  cases  where 
the  elongation  of  the  mesentery  is  a  conspicuous  feature  a 
congenital  origin  may  probably  be  ascribed  to  the  condition. 
In  a  case  of  volvulus  reported  by  Dr.  Fowler,  the  mesentery 
of  the  involved  coil  measured  from  seven  to  eight  and  a  half 
inches  from  its  root  to  its  attachment  to  the  bowel.!  Dr. 
N.  Pitt§  describes  a  case  of  volvulus  of  some  three  feet  of  the 
ileum  in  a  new-born  infant  who  died  of  intestinal  obstruction 
two   days  after  birth.     The  twisted  bowel  Avas  almost  black 

*  Trans.  Eoy.  Med.  Chir.  Soc,  1895,  p.  117. 
t  Ann.  of  Univer.  Med.  Sci.,  1894,  vol.  iii. 
X  lancet,  vol.  i.,  1883,  p.  1119. 
§  Trans.  Patli.  Soc,  Lond.,  vol.  xlii. 


VOLVULUS    OF   SMALL    I^^TEST1NE.  137 

from  strangulation.     Mr.  Harrison  Cripps*  reports  an  almost 
identical  case.     The  infant  died  three  days  after  birth. 

The  mechanism  of  the  volvulus  and  the  exact  means 
whereby  it  is  brought  about  are  still  matters  of  speculation. 
The  twist  is  usually  from  left  to  right,  and  as  a  rule 
represents  one  complete  turn.  Fatal  obstruction  may,  how- 
ever, follow  in  instances  where  the  bowel  has  described  but 
half  a  turn.t 

Dorfler  reports  a  case  in  which  the  bowel  was  twisted 
several  times  upon  itself  J  Distension  of  the  involved  coil  has 
evidently  much  to  do  with  the  volvulus.  In  two  or  three 
instances  it  was  noticed  at  the  autopsy  that  the  twist  became 
spontaneously  reduced  when  the  bowel  was  punctured,  but 
reappeared  when  it  was  again  inflated.  § 

A  volvulus  may  appear  to  be  due  to  a  congenital  defect  in 
the  bowel.  Thus  Dr.  Rolleston]!  describes  a  case  of  volvulus 
of  the  ileum  five  and  a  quarter  inches  from  the  csecum.  The 
caecum  had  not  descended  into  the  right  ihac  fossa  but  lay 
over  the  right  kidney,  to  which  it  was  fixed  by  peritoneum. 
The  lower  five  inches  of  the  ileum  had  no  mesentery,  this 
portion  of  the  gut  was  bound  down  to  the  posterior  wall  of 
the  abdomen  and  the  peritoneum  passed  in  front  of  it. 
There  was  no  trace  of  inflammation  in  the  neighbourhood, 
and  the  appendix  was  normal.  Where  the  fixed  abnormal 
ileum  joined  the  free  mesentery-possessing  ileum  the  vol- 
vulus had  occurred.  The  patient  was  a  man  aged  fifty- 
eight  who  died  of  the  volvulus. 

The  general  appearance  of  a  simple  volvulus  of  the  small 
intestine  is  well  shown  in  Fig.  50  fi-om  a  specimen  in  St. 
Thomas's  Hospital  The  involved  coil,  having  its  blood-vessels 
compressed  and  being  closed  at  both  ends,  becomes  greatly 
distended.  This  distension  may  cause  it  to  attain  huge 
dimensions,  as  in  a  case  of  volvulus  of  the  duodenum  recorded 
by  Dr.  Rombold,  where  the  twisted  loop  looked  like  the 
stomach,  and  is  said  to  have  been  larger  than  an  adult's 
head.^ 

The  walls  of  the  distorted  loop  are  deeply  congested,  may 
be  black  in  colour,  or  in  a  condition  of  approaching  gangrene. 
I  have  met  with  no  instance  where  the  intestinal  wall  had 
given  way  during  life. 

*  Trans.  Path.  Soc,  Lond,,  vol.  xxxi. 

t  See  case  bv  Dr.  Sutton  ;  Brit.  Med.  Journ.,  vol.  i.,  1881,  p.  848. 
+  Munch,  med.  Woch.,  Dec.  26,  1893. 

\j  As  an  instance,  sec  case  by  Dr.  A'erneuil  ;  Bui],  de  la  Soc.  Anat ,  1870, 
p.  411. 

I!   Path.  Soc.  Trans.,  1890,  p.  12 7- 

\\  Oeetreichische  Zeitschrift  ftir  prakt.  Heilkunde,  1865,  X.  6. 


138 


MORBID    ANATOAIY. 


The  amount  of  bowel  involved  in  tlie  present  form  ot 
obstruction  varies  greatly.  In  the  majority  of  the  cases  a 
large  loop,  probably  about  one  foot  to  two  feet  in  length,  is 
implicated.  In  one  or  two  instances  five  feet  of  bowel  were 
discovered  to  have  been  twisted."^ 

Ashby  t  reports  a  case,  associated  with  adhesions,  in  which 
nearly  the  whole  of  the  small  intestines  was  twisted. 


Fig.  50. — Volvulus  of  Lower  Ileum. 

A'  and  A^  join  one  anotlier  alter  many  convolutions. 


As  regards  the  segment  ot  bowel  involved,  the  twist 
concerns  most  often  the  lower  ileum.  Volvulus  is  said  to 
have  been  found  in  the  duodenum — as  in  the  case  of  Dr. 
Rombold's  above  alluded  to — and  in  several  instances  the 
twist  has  been  limited  to  some  part  of  the  jejunum.     For 

*  Dr.  James  Wilson;  Amer.  Jotirn.  of  Med.  Sciences,  July,  1879,  p.  78:  and 
Dr.  Hector  Mackenzie  ;  Trans.  Path.  Soc,  1890,  -p.  127. 
t  Brit.  3Ied.  JtHirn.,  1891,  vol.  i.,  p.  413. 


VOLVULUS    OF   SMALL    INTESTINE.  139 

example  Stanley^  describes  the  case  of  a  cliild  aged  five 
years,  who,  after  a  slight  blow  on  the  abdomen,  developed 
symptoms  of  acute  obstruction,  which  ended  in  death  in 
forty-eight  hours.  The  autopsy  revealed  a  volvulus  about 
thirty  inches  from  the  pylorus. 

The  majority  of  the  patients  Avho  have  exhibited  this 
form  of  volvulus  have  been  males,  and  the  mean  age  in 
a  number  of  cases  I  have  collected  was  twenty-five  years. 
I  have  mentioned  that  this  form  of  obstruction  has  been 
met  with  in  newly-born  infants  ;  it  has  also  occurred  in 
youn^  children  between  the  ages  of  three  and  ten.  t  It 
would  seem  to  be  quite  rare  after  forty. 

In  a  certain  number  of  cases  the  volvulus  would  appear 
to  have  followed  a  blow  or  injury.  Hawkins  :j:  details  the 
case  of  a  woman  who  died  from  acute  intestinal  obstruction 
forty-eight  hours  after  a  slight  fall  from  a  chair.  The 
autopsy  revealed  a  figure-of-eight  twist  of  the  bowel. 

Pennington  §  reports  the  case  of  a  girl  of  eighteen  who 
died  of  a  twist  of  the  ileum  which  came  on  after  violent 
exercise. 

A  case  by  Stanley  has  just  been  alluded  to,  and  attention 
may  also  be  drawn  to  Mr.  Turner's  case,  described  on  page  140. 

I  might  here  point  out  that  certain  reputed  instances  of 
volvulus  of  the  small  intestine — especially  those  attended  by 
peritonitis— may  be  liable  to  some  question  as  to  the  reality  of 
the  diagnosis.  When  the  abdomen  is  opened  in  cases  attended 
with  the  symptoms  of  peritonitis,  the  surgeon,  in  searching  for 
the  cause  of  the  trouble,  is  apt  to  be  misled  by  the  confusion 
with  which  the  coils  of  small  intestine  are  disposed,  and  as 
these  coils  are  heightened  in  colour,  and  as  in  separating 
them  he  may  appear  to  be  untwisting  them,  there  are  some 
bases  for  a  not  unreasonable  mistake. 

Two  cases  are  within  my  own  knowledge  which  have 
much  confirmed  the  above  impression.  In  both  these  cases 
a  diagnosis  of  intestinal  obstruction  had  been  made,  in  both 
a  laparotomy  was  performed  and  the  surgeon  reported  a 
volvulus  of  the  small  intestine  with  peritonitis.  The  patients 
died,  and  in  each  case  there  was  revealed  a  perforative 
peritonitis  around  the  vermiform  appendix  on  the  one  hand, 
and  no  evidence  of  volvulus  of  the  bowel  on  the  other. 

(B)  Two  Suitable  Coils  of  Small  Intestine  are  Twisted 

*  Quoted  by  Maylard  ;  Surgery  of  the  Alimentary  Canal,  p.  390, 
t  See  for  example  a  case  in  a  child  of  five  recorded  by  Mr.  Stavely  in  the 
Medical  Society's  Transactions,  vol.  xvi.,  p.  19. 
t  Med.  Soc.  Trans.,  vol.  xvi.,  1893,  p.  18. 
§  Annual  of  the  Univer.  Med.  Sci.,  vol,  iii.,  1894. 


140 


MORBID    ANATOMY. 


Together,  the  one  acting  as  an  axis  about  which  the  other 
is  wound.  The  suitabihij  consists  in  the  involved  loop  being 
possessed  of  a  long  and  narrow  mesentery,  or  of  the  loop  that 
forms  the  axis  being  fixed  by  its  extremity  to  some  point  on 
the  parietes.  Such  a  case  is  shown  in  the  accompanying 
diagram  from  Leichtenstern,  where  the 
axial  loop  was  adherent  to  the  parietes 
at  the  pomt  a  (Fig.  51);  b  points  to  the 
coil  that  was  twisted  about  the  axial 
loop. 

This  form  of  volvulus  is  very  rare. 
It  would  appear  that  the  symptoms  to 
which  it  gives  rise  are  of  an  acute  char- 
acter, as  is  often  seen  in  like  forms  of 
volvulus  where  two  coils  of  bowel  are 
involved,  one  coil  being  composed  of 
small  intestine. 

Dr.  Bundle  describes  an  autopsy 
where  two  adjacent  coils  of  small  in- 
testine were  found  to  be  adherent,  while  around  them  a  third 
segment  of  the  lesser  bowel  had  become  twisted.  The  patient 
was  a  man,  aged  forty,  who  was  seized  with  sudden  and 
severe  abdominal  pain  associated  with  vomiting.  Collapse 
soon  appeared,  and  he  died  in  less  than  twenty-four  hours.* 

Attention  has  already  been  drawn  to  cases  where  a 
volvulus  has  been  formed  by  an  intertwining  between  a  loop 
of  small  intestine  on  the  one  hand  and  the  sigmoid  flexure, 
or  an  abnormal  caecum  or  ascending  colon,  on  the  other. 

As  an  example  of  the  form  of  volvulus  now  under  con- 
sideration may  be  quoted  the  following  case  recorded  by 
Mr.  George  Turner.t 


Fig.  51. — Volvulus  of  Small 
Intestine  {Leichtenstern). 


A  boy,  aged  seven,  was  admitted  into  the  Seamen's  Hospital  at 
8.15  p.m.,  on  July  26,  1891,  with  the  history  of  having  fallen  from  a 
height  of  twelve  feet  against  the  pole  of  a  boat,  and  then  intothe  mud 
of  the  river.  He  was  much  collapsed,  and  vomited  several  times,  the 
vomited  matter  being  bilious.  There  was  great  pain  in  the  abdomen, 
especially  in  the  right  iliac  region,  where  there  was  considerable  tender- 
ness. There  was  no  abdominal  distension.  The  knees  were  kept  drawn 
up,  and  the  patient  was  remarkably  restless.  There  was  tenesmus,  but 
neither  flatus  nor  faeces  was  passed.  Laparotomy  was  performed  twenty- 
four  hours  after  the  accident.  There  was  no  evidence  of  rupture  of  any 
viscus  ancl  no  peritoneal  effusion.  Two  coils  of  ileum  were  found  con- 
cerned in  a  volvulus,  one  coil  being  twisted  around  the  other.  The  two 
coils  were  respectively  one  foot  and  two  feet  in  leDgth,  and  these  were 
separated  by  some  three  or  four  feet  of  normal  intestine.  ""'"  —i ""•"■' 
was  untwisted,  and  the  patient  made  a  rapid  recovery. 

*  Med.  Times  and  Gazette,  vol.  i.,  1866,  p.  306. 
f  Med.  iSoc.  Tians,,  vol.  xvi.,  1893,  p.  16. 


The  volvulus 


141 


CHAPTER    VI. 


INTUSSUSCEPTIOISr. 


By  the  term  intussusception  is  understood  the  prolapse  of 
one  part  of  the  intestine  into  the  lumen  of  an  immediately 
adjoining  part.  In  cases  where  the  extremity  of  the  ileum 
is  protruded  through  the  ileo-csecal  valve  into  the  colon, 
the  term  prolapse  is  singularly  appropriate.  In  other  cases, 
as,  for  example,  in  intussusceptions  limited  to  the  small  or 
to  the  large  intestine,  the  condition  may  be  better  expressed 
by  saying  that  one  part  of  the  circuml'erence  of  the  bowel 
has  been  turned  into  the  part  adjacent  to  it. 

Intussusception  is  a 
very  common  form  of 
intestinal  obstruction. 
Classing  all  varieties  of 
obstruction  together,  it 
forms  more  than  one- 
third  of  the  whole.  Its 
actual  share  is  probably 
represented  by  three- 
eighths.  Among  1,152'^ 
cases  of  intestinal  ob- 
struction of  all  kinds  col- 
lected by  Leichtenstern 
are  no  less  than  442 
cases  of  intussusception.  In  a  special  monograph  upon  the 
subject  this  author  deals  with  the  substantial  total  of  593 
recorded  cases.t 

Terms  employed. — If  an   intussusception   be  viewed    in 
vertical  section  it  will  be  seen  to  be  composed  of  six  layers 

*  From  this  collection  are  excluded  congenital  obstructions,  stenoses  of  tlie 
rectum,  and  the  various  forms  of  hernia. 

t  Viertel  Jahrschrift  f.  d.  prakt.  Heilk.    Fragne,  1873-4. 


■  V 


Yvi.  52. — Vertical  and  Transverse  Sections  of 
an  Intussusception. 

a,  the  sheath  or  intussuscipieiis  ;  5,  the  entering  or 
inner  layer ;  c,  the  returning  or  middle  layer  ;  d, 
the  neck. 


142 


PATHOLOGY   OF   INTU8SUSGEPTI0K 


of  intestine,  three  on  eacli  side  of  the  central  canal,  all 
more  or  less  parallel  to  one  another.  It  will  be  noticed 
also  that  the  arrangement  of  the  layers  is  such  that  mucous 
membrane  lies  in  contact  with  mucous  membrane,  and 
peritoneum    with    peritoneum.     On    horizontal    section    the 


Fig.  53. — Intussusception  of  Jejunum. 
a,  internal  cylinder  ;   b,  middle  cylinder ;   c,  external  cylinder. 


invaginated  mass  will  show  three  concentric  rings  of  bowel, 
with  of  course  the  same  mutual  relations  with  regard  to 
the  mucous  and  serous  surfaces  (Fig.  52). 

All  parts  of  the  intussusception  are  named,  and  the 
nomenclature  has  suffered  somewhat  from  an  exuberance 
of  terms.  The  external  of  the  three  layers  is  known  as 
the  intussuscipiens,  the  sheath,  or  the  receiving  layer  (la 
gatne  of  the  French,  Fig.  52,  a).  The  innermost  cylinder 
is  known  as  the  entering  layer  (Fig.  52,  6),  and  the  middle 
one    as  the    returning   layer  (Fig   52,   c).      Taken    together, 


VARIETIES    OF   INTUSSUSCEPTION. 


143 


these  two  layers  form  the  intussusceptnm  {le  bond  in  of 
the  French).  The  "  neck "  of  the  intussusception  is  at 
its  upper  part,  where  the  returning  layer  joins  the  sheath 
(Fig.  52,  d).  The  ridge  formed  by  the  junction  of  these 
two  layers  is  known  as  le  boiirrelet.  The  "  apex "  of  the 
intussusception  is  at  the  lower  part  of  the  intussusceptum, 
where  the  entering  and  returning  layers  join.  The  ar- 
rangement of  the  various  parts  of  an  intussusception  is 
well   shown   In  Fig.  53.      All  intussusceptions  are   complete 


FiO.  54, — ^Intussusception  of  the  Jejunum,  one  inch  and  a  half  in  length. 

{Royal  Coll.  of  Surg.  Mus.,  No.  2098  A.) 


in  the  sense  that  the  intussusceptum  is  composed  of  all 
the  coats  of  the  bowel,  and  that  it  enters  the  sheath 
evenly  and  equally.  Some  authors  have  described  partial 
or  lateral  intussusceptions.  In  these  cases  a  polyp  exists, 
and  by  a  dragging  upon  the  tumour  the  part  of  the  in- 
testinal wall  to  which  it  is  attached  is  drawn  into  the 
lumen  of  the  gut,  so  as  to  form  a  slight  funnel-like  de- 
pression on  the  surface.  Such  invaginations  do  not  enter 
into  the  present  category. 

Anatomical  Varieties. — Invaginations  may  occur  at  any 
part  of  the  intestine  from  the  duodenum  to  the  rectum. 
They  may  be  conveniently  divided  into  three  classes :  (1)  the 
enteric;  (2)  the  colic  or  rectal;  (3)  the  intussusceptions 
which  involve  the  ileo-csecal  segment  of  the  bowel. 

(1)  Enteric  invaginations  may  occur  in  any  part  of 
the  lesser  bowel.  In  the  upper  part  of  the  small  intestine 
they   are   rare,   although  an    isolated   case   or   so    has   been 


144  PATHOLOGY   OF   INTUSSUSCEPTION. 

recorded  of  reputed  intussusception  of  the  duodenum.  Dr. 
Delepine*  records  a  case  in  which  the  duodenum  was 
dragged  into  an  ileo-csecal  intussusception.  They  are  most 
common  in  the  lower  jejunum  and  then  in  the  ileum.  Dr. 
Hale  White  reports  a  fatal  intussusception  in  a  man  of 
thirty,  which  involved  the  jejunum  two  feet  six  inches  from 
the  pylorus.t     {See  Figs.  53,  62,  63,  and  64.) 

It  would  appear  that  jejunal  intussusceptions  bear  to 
ileic  intussusceptions  the  proportion  of  about  4  to  1. 
Invaginations  involving  the  small  intestine  seldom  attain 
great  length.  They  are  often  very  short,  and  in  the  majority 
of  cases  do  not  involve  more  than  a  few  inches  of  the 
bowel,  about  three  to  ten  inches,  on  an  average.  In 
several  instances  an  intussusception — mostly  in  the  jejunum 
— measuring  one  inch  to  one  inch  and  a  half  has  caused 
death  (Fig.  54). J  Some  may  be,  however,  of  considerable 
length,  as  in  a  case  reported  by  Mr.  Henry  Morris,  where  two 
feet  of  the  lower  ileum  were  involved ;  §  or  another,  recorded 
by  M.  Bucquoy,  where  over  two  yards  of  jejunum  were 
implicated  in  the  invagination.  || 

Under  this  class  must  be  included  the  great  majority 
of  "  the  intussusceptions  of  the  dying."     {See  Fig.  56.) 

(2)  Colic  intussusceptions  present  many  varieties.  The 
ascending  colon  may  be  invaginated  into  the  transverse,  the 
transverse  into  the  descending,  and  the  descending  colon  into 
the  sigmoid  flexure.  They  are  most  frequently  met  with 
in  the  two  last-named  parts  of  the  colon.  Owing  to  the 
comparative  fixity  of  the  large  intestine,  it  happens  that  these 
intussusceptions  are  usually  short,  and,  indeed,  taken  as  a 
whole,  they  form  invaginations  which  in  point  of  size  arc 
the  smallest  of  the  whole  series.  When  the  rectum  is  in- 
volved the  upper  segment  of  this  intestine  is  invaginated 
into  the  lower  part.  Such  intussusceptions  must  of  necessity 
be  short,  since  in  the  most  extreme  cases  they  must  bo 
limited  by  the  length  of  the  rectum  itself,  {See  Figs.  60  and  71.) 

(3)  The  intussusceptions  that  occur  in  the  iLEO-d:cAr. 
REGION  may  be  divided  into  two  main  classes :  the  ileo-ca^cal 
and  the  ileo-colic. 

The   ileo-ccecal   form   is   the   commonest    variety    of    in- 

*  Path.  Soc.  Trans.,  1891,  p.  124. 
t  Ibid.,  1890,  p.  121. 

I  See  Museum  of  the  Roy.  Coll.  of  Surgeons.     Specimens  2698  A,  2701. 

§  Path.  Soc.  Trans.,  vol.  xxviii.,  p.  131.  See  also  case  by  Mr.  Eao-er  {Lancet, 
vol.  i.,  1882,  p.  604),  where  one  foot  and  a  half  of  the  upper  jejunum  was 
involved. 

II  Recueil  dea  Travaux  de  la  Soc.  Med.  d'Observ,  tome  i.,  p.  192.  Paris, 
1857.  See  also  case  by  Dr.  Johnstone,  of  Baltimore  {Lancet,  vol.  i.,  1883,  p.  176), 
'I'here  forty  inches  of  small  gut  were  passed  by  the  anus,  with  recovery. 


GROWTH    OF   Ay   INTUSSUSCEPTWX.  U5 

vagination,  while  the  ileo-coUc  is  the  most  rare.  In  the 
former  the  ileum  and  coeciim  pass  into  the  colon  preceded 
by  the  ileo-ciecal  valve.  The  internal  cylinder  is  formed 
by  the  termination  of  the  ileum;  the  external  cylinder  or 
sheath  is  formed  by  the  colon  alone,  while  the  apex  of  the 
intussusception  is  represented  by  the  ileo-ctecal  valve.  This 
form  may  attain  great  size,  and  it  is  not  infrequent  for  the 
valve  to  traverse  the  whole  length  of  the  large  intestine,  and 
ultimately  present  itself  at  the  anus  or  even  protrude  through 
the  sphincter.     (Fig.  61.) 

In  the  ileo-colic  variety  the  termination  of  the  ileum  is 
prolapsed  through  the  ileo-ciecal  valve.  The  valve  and 
ca3cum  remain,  for  a  time,  at  least,  in  their  normal  situations. 
The  apex  of  the  intussusceptum  must  always  be  formed 
by  some  portion  of  the  terminal  part  of  the  ileum.  This 
intussusception  is  commonly  associated  with  some  secondary 
invagination  of  the  c;Tecuin  and  colon  itself,  concerning  which 
more  will  be  said  when  speaking  of  the  mode  of  increase 
observed  in  these  conditions  of  the  bowel.     (Fig.  55.) 

A  third  variety  met  with  in  this  region  has  been  termed  by 
Leichtenstern  the  iliaca-ileo-colica.  In  this  form  a  primary 
intussusception  is  formed  in  the  terminal  part  of  the  ileum. 
This  invagination,  when  it  reaches  the  valve,  may  either  pass 
through  it  (just  as  does  the  uninvaginated  gut  in  the  pure 
ileo-colic  form)  ;  or  it  may  be  arrested  at  the  valve,  and  then 
be  associated  with  an  invagination  of  the  caecum  into  the 
ascending  colon.  In  the  lormer  of  these  two  sub-varieties 
the  apex  of  the  intussusception  will  be  formed  of  ileum ; 
in  the  latter  it  will  be  represented    by  the  ileo-csecal  valve. 

Allusion  is  made  later  (page  181)  to  invagination  of  the 
vermiform  appendix. 

Relative  Frequency  of  the  Various  Forms. — According 
to  Leichtenstern,  whose  statistics  are  by  far  the  most 
numerous  at  present  published,  the  different  anatomical 
varieties  are  thus  distributed  in  one  hundred  cases :  Ileo- 
cajcal,  44  per  cent. ;  enteric,  30  per  cent. ;  colic  (including 
rectal),  18  per  cent. ;  and  ileo-colic,  8  per  cent.  With  these 
results  the  statistics  published  by  Brlnton  and  others  very 
closely  agree. 

The  Mode  of  Growth  of  the  Intussusception. — In  all 
the  forms,  Avith  the  exception  of  the  ileo-colic,  the  method 
of  increase  is  as  follows  :  When  an  intussusception  increases 
in  length  after  a  piece  of  bowel  has  been  primarily  in- 
vaginated,  the  increase  is  at  the  expense,  not  of  the  entering 
layer,  but  of  the  external  or  receiving  layer.  For  example, 
let  it  be  supposed  that  a  portion  of  the  termination  of  the 
K 


146  PATHOLOGY    OF   INTUSSUSCEPTION: 

jejunum  is  invaginated  into  the  ileum.  If  the  mass  increase 
in  length  it  will  do  so  solely  at  the  expense  of  the  ileum. 
No  more  of  the  jejunum  will  actively  enter  into  the  intus- 
susception, so  that  no  matter  what  segment  of  gut  formed 
the  original  apex  of  the  intussusception,  that  apex  will 
remain  the  same  even  if  the  invaofination  doubled  or  trebled 
its  original  length.  In  the  ileo-csecal  variety  the  cjecum  is 
turned  into  the  ascending  colon,  and  t,he  valve  forms  the  apex 
of  the  intussusception.  As  the  invagination  increases  the 
ascending  colon  becomes  inverted,  then  the  transverse  and 
descending  colon,  until  at  length,  when  the  sigmoid  flexure 
is  reached,  no  trace  of  the  ascending,  nor  probably  of  the 
transverse,  colon  will  be  left,  but  the  valve  will  still  form 
the  tip  of  the  intussusception.  It  is  obvious  that  in  the 
growth  of  this  variety  much  depends  upon  the  mobility  of 
the  colon,  and  since  the  colon  is  usually  much  less  fixed  in 
the  child  than  it  is  in  the  adult  it  follows  that  extensive 
invaginations  of  this  species  are  most  commonly  met  with 
in  the  young. 

The  occasional  condition  in  which — as  a  congenital 
anomaly — the  whole  of  the  colon  is  found  to  be  suspended 
by  a  liberal  mesocolon  no  doubt  favours  intussusception  of 
the  colon  and  favours  the  extension  of  those  which  reach 
the  colon. 

In  many  examples  of  extensive  intussusception  this  con- 
genital defect  in  development  was  in  evidence. 

The  amount  of  traction  brought  to  bear  upon  the  parts 
of  a  growing  intussusception  which  involves  the  colon  must 
often  be  considerable.  This  is  well  illustrated  in  a  specimen 
in  St.  Bartholomew's  Hospital.^  It  shows  an  ileo-csecal  intus- 
susception. The  csecum,  the  ascending  and  transverse  colon 
have  disappeared  from  view,  the  ileum  appears  to  enter 
directly  into  the  descending  colon.  The  vermiform  appendix 
and  the  ileo-csecal  valve  project  beyond  the  anus.  By  means 
of  the  dragging  upon  the  transverse  colon  the  stomach  has 
been  rendered  vertical,  and  has  been  brought  ^nto  close 
contact  with  the  intussusception. 

In  the  ileo-colic  variety  the  method  whereby  the  intussus- 
ception increases  is,  in  the  first  instance,  at  least,  somewhat 
different.  A  portion  of  the  terminal  ileum  is  protruded 
through  the  ileo-cascal  valve,  and  the  invagination  may  increase 
for  some  time  solely  by  the  prolapse  of  more  and  more  ileum, 
the  sheath  remaining  perfectly  unchanged.  This  is  exactly 
the  opposite  to  what  happens  in  other  intussusceptions. 
When  once  the  prolapse  has  commenced   no   obstacles   are 

*  St.  Bart.'s  Hosp.  Museum,  No.  2188, 


GRowTir  OF  A?{  tntussusception: 


147 


offered  to  its  increase  other  than  those  presented  by  the 
resistance  of  the  valve  and  the  dragging  upon  the  ileic 
mesentery.     When  once    the    invaginated   small  intestine  is 


Fm.  55. — Ileo-colic  Intussusception. 
a,  ascending  colon  ;    b,  ileum  ;    c,  vermiform  appendix. 


in  the  spacious  colon  it  meets  with  practically  no  resistance. 
Sooner  or  later,  however,  no  more  ileum  can  become  pro- 
lapsed. The  part  protruded  may  become  fixed  by  adhesions  ; 
or  from  congestion  or  distension  of  the  ileum  the  valve  offers 
a  rigid  resistance  to  any  further  invasion  of  the  colon.     In 


148  PATHOLOGY    OF   INTUSSUSCEPTION 

such  a  case,  if  the  mtussusception  still  continues  to  increase 
it  must  do  so  by  the  method  observed  in  other  forms  of 
invagination,  viz.  at  the  expense  of  its  sheath.  No  more 
ileum  can  enter,  but  the  caecum  can  be  turned  in,  and 
then  the  ascending;-  colon,  and  so  on  until  at  last  the  rectum 
may  be  reached.  A  good  specimen  of  ileo-colic  intussuscep- 
tion associated  with  little  or  no  secondary  invagination  of 
the  csecum  is  shown  in  Fig.  55  from  the  museum  of  the 
Royal  College  of  Surgeons. 

The  Intussusception  of  the  Dying-. — All  invaginations 
can  be  divided  into  two  great  forms  according  to  the  circum- 
stances of  their  origin. 

(1)  The  common  or  obstructive  intussusception  and  (2) 
the  intussusception  of  the  dying,  or  as  some  call  it,  the  agonic 
intussusception.  With  the  former  only  is  surgery  concerned. 
The  latter  is  a  form  of  invagination  which  occurs  probably  a 
little  Avhile  before  death,  and  depends  upon  certain  irregular 
peristaltic  movements  that  may  be,  conceived  to  occur 
during  the  act  of  dying.  It  is  well  known  that  as  a  patient 
lies  in  articido  mortis  muscular  actions  become  often 
irregular  and  disordered  before  they  cease  for  ever.  It  is 
consistent  with  experience  to  imagine  that  a  like  feebly 
tumultuous  action  may  pervade  the  muscle  of  the  intestine 
during  the  death  struggle,  and  that  it  may  be  such  as  to 
produce  some  invagination  of  the  bowel.  Intussusceptions  of 
this  kind  cause  no  symptoms  during  life.  They  are  first 
discovered  at  the  autopsy.  They  are  always  very  small,  are 
always  free  from  any  trace  of  congestion  or  inflammation,  and 
interfere  little  with  the  lumen  of  the  bowel.  With  the  most 
trifling  amount  of  traction  they  can  be  reduced.  They  are  most 
usually  met  with  in  children,  and  especially  in  such  as  have 
died  of  brain  disease.  The  more  marked  irritability  of  the 
bowel  in  children  may  account  for  this,  and  it  may  be  noted 
that  even  in  children  these  intussusceptions  are  most  common 
in  the  quite  young,  or  at  least  in  those  under  ten  years  of  age. 
They  may  be  said  to  be  uncommon  in  adults.  They  occur  in 
association  with  perfectly  normal  abdominal  viscera.  They 
may  be  found  in  connection  with  an  existing  intussusception 
of  the  obstructive  type.  When  I  was  engaged  in  the  post- 
mortem room  at  the  Zoological  Gardens  I  was  struck  with 
the  fact  that  in  nearly  all  the  monkeys  that  had  been  put  to 
death,  for  one  reason  or  another,  this  form  of  intussusception 
Avas  to  be  found.  In  those  that  died  a  natural  death  I  saw 
no  instance  of  this  invagination,  and  I  do  not  remember  to 
have  seen  an  example  of  the  obstructive  intussusception  in 
these  particular  animals. 


INTUSSUSCEPTION'    OF    THE    DYING.  149 

In  two  other  points  may  the  intussusception  of  the  dying 
ditier  from  common  intussusceptions,  viz.  in  number  and  in 
direction.  These  points  may  be  considered  in  more  detail. 
The  obscructive  invagination  is  usually  single :  the  intus- 
susceptions of  the  dying  are  often  multiple.  There  are  a 
few  recorded  cases  where  several  intussusceptions  have  been 
found  which  collectively  caused  obstruction  and  which  were 
apparently  not  of  the  precise  nature  of  those  that  form  just 
before  death.  The  multiple  invaginations  are  always  small 
and  nearly  always  limited  to  the  small  intestine,  while  at  the 
same  time  they  are  associated  with  but  slight  changes  in  the 
gut.  The  common  obstructive  intussusception  which  is  asso- 
ciated with  adhesion  of  its  parts,  with  gross  changes  in  both 
its  sheath  and  its  intussusceptum,  and  often  with  gangrene 
of  the  latter  is.  so  far  as  I  can  ascertain  from  the  records  of 
cases,  practically  always  single.  It  is  true  that  such  in- 
vaginations may  be  associated  with  others  which  are  secondary 
to  it  and  Avhich  are  clinically  of  no  significance ;  but  instances 
Avhere  two  obstructive  intussusceptions  distinctly  independent 
of  one  another,  and  both  attended  by  such  morbid  changes 
as  are  common  in  such  invaginations,  have  existed  at  the 
saiue  time  in  the  same  body  are  exceedingly  rare. 

A  case  of  this  kind  is  given  by  Mr.  D'Arcy  Power."^  The 
patient  was  a  boy  aged  five  months,  who  was  attacked  with 
symptoms  of  acute  intussusception,  and  died  on  the  tifth  day. 
Two  intussusceptions  were  discovered,  one  at  the  ileo-ca^cal 
valve  about  two  inches  in  lenoj-th,  and  one  in  the  transverse 
colon  which  measured  a  little  more  than  an  inch  in  length. 
The  latter  invagination  was  ascending,  or  retrograde,  and  may 
have  been  induced  by  t?he  injections  of  water  and  of  air  which 
were  administered  during  life. 

In  both  cases  recently-formed  lymph  had  glued  together 
the  contiguous  walls  of  the  gut.  The  upper  intussusception 
showed  signs  of  gangrene.  Mr.  PoAver  alludes  to  two  cases, 
one  reported  by  Mr.  Poiegrine  t  and  one  by  Dr.  Handtield 
Jones.j  Avhich  he  maintains  to  have  been  both  similar  to 
his  own  case. 

The  intussusceptions  of  the  moribund,  on  the  other  hand, 
are  more  often  multiple  than  single.  It  is  common  to  find 
four  or  five  within  a  little  distance  of  one  another,  and  even 
as  many  as  ten  have  been  met  with  in  a  single  case.§ 

In   direction   the  obstructive   intussusception   is    almost 

*  Trans.  Path.  Soc,  1886,  p.  240. 
t  Laiictt,  vol.  i.,  1873,  p.  709. 
X  Med.-Chir.  Soc.  Trans.,  vol.  Ixi..  p.  301, 

§  Dr.  Geo;  Brit.  Med.  Jonni.^  Nov.  14,  1861.      See  also  ilr.   Gay's  paper  en 
Intussusception.     London,  18C2. 


150  FATHOLOGY   OF   INTUSSUSCEPTION. 

invariably  descending,  i.e.  the  in-turning  of  the  bowel  wall 
is  in  the  direction  of  the  anus.  It  is  true  that  a  primary 
invagination  of  this  kind  may  be  associated  with  a  secondary 
ascending  intussusception. 

But  such  secondar}^  formations  are  unimportant,  have 
little  or  no  influence  upon  the  primary  trouble,  and  are 
devoid  of  any  cHnical  significance.  The  intussusceptions  of 
the  dying  are  often  ascending  or  retrograde,  and  the  two 
varieties  are  not  infrequently  found  to  be  present  in  the  same 
body.  A  specimen  of  such  a  case  is  to  be  found  in  Guy's 
Hospital,"^  while  Fig.  56  t  shows  the  common  appearance  of 
the  invaginations  of  the  moribund. 


Fig.  56.— Intussusception  of  the  Dying. 

These  non-clinical  intussusceptions  have  formed  the  bases 
of  njany  erroneous  conclusions,  and  have  been  accredited  wiih 
producing  an  obstruction  which  may  have  existed  for  days 
and  Aveeks  before  they  themselves  had  any  existence.  A 
case  reported  by  M.  Leger  j  may  probably  be  an  example  of 
this.  A  woman  of  sixty-five  died  after  presenting  symptoms 
of  chronic  obstruction  which  had  extended  over  twelve 
months.  She  died  of  inanition.  The  autopsy  revealed  an 
intussusception  of  the  upper  part  of  the  jejunum  18  cm.  in 
length.  This  invagination  presented  no  adhesions,  and 
showed  an  absence  of  congestion,  and  indeed  of  any  other 
morbid  changes  in  its  Avails.  It  is  extremely  improbable  that 
this  intussusception  could  have  induced  abdominal  symptoms 
for  over  twelve  months,  and  jet  after  death  be  found  to  be 
as  free  from  structural  changes  as  a  piece  of  intestine  but 
recently  invaginated.  The  diagnosis  of  chronic  intussus- 
ception presupposes  that  the  iuA^agination  had  existed  un- 
reduced for  the  period  covered  by  the  symptoms.  Elsewhere 
in  the  abdomen  Avere  ancient  adhesions  the  products  of  a  past 

*  No.  1851  (42).         t  St.  Thomas's  IIosp.  IMusfuin,  No.  11  2. 
J  Bull,  de  ]a  Soc.  Amtt.  1S76,  p.  719. 


RETROGRADE    INTUSSUSCEPTION.  151 

peritonitis.  It  would  be  more  reasonable  to  assume  that  the 
chronic  obstruction  was  due  to  the  adhesions,  and  that  the 
intussusception  was  of  the  character  of  those  which  form 
when  the  patient  lies  in  articido  raortis.  Another  case  of  a 
different  nature,  reported  by  M.  Le  Moyne,"^  may  possibly  fall 
under  the  present  category.  The  patient,  a  man  aged  thirty- 
five,  died  with  symptoms  of  subacute  obstruction.  The 
autopsy  revealed  six  intussusceptions  of  the  small  intestine. 
They  were  all  small,  readily  reduced,  and  free  from  any 
structural  or  vascular  changes.  The  sigmoid  flexure  was 
blocked  with  a  mass  of  faecal  matter  and  undigested  food, 
which  formed  so  large  a  collection  as  to  produce  a  tumour 
whi(.'h  was  seen  through  the  parietes  several  days  before  death. 
In  this  instance  I  would  venture  to  suggest  that  the  mass  in 
the  colon  more  probably  caused  the  fatal  obstruction  than 
did  the  intussusceptions  which  all  possessed  a  lumen  large 
enough  to  admit  the  point  of  the  little  finger. 

Retrograde,  Double,  and  Triple  "intussusceptions. — 
These  unusual  forms  may  conveniently  be  considered  here. 
It  has  been  already  said  that  the  common  or  obstruc- 
tive invagination  is  almost  invariably  descending  as  regards 
its  direction.  To  this  observation  there  are  very  few  ex- 
ceptions. Out  of  a  collection  of  593  cases  Leichtenstern 
could  find  only  eight  examples  of  a  primary  ascending  or 
retrograde  intussusception  of  the  obstructive  (or,  as  he  calls  it, 
of  the  inflammatory)  variety.  He  considers  that  these  eight 
instances  all  depended  upon  a  rare  association  of  anomalous 
circumstances,  and  regards  them  all  as  allied  to  the  invagi- 
nations of  the  death-struog-le,  amons*  which  retrograde  forms 
are  by  no  means  uncommon.  A  case  or  two,  however,  of 
retrograde  intussusception  of  the  obstructive  variety  may  be 
named  which  would  appear  to  be  of  less  complicated  origin 
than  Leichtenstern  is  disposed  to  admit.  Such  a  case  is 
reported  by  M.  Besnier.f  It  concerns  a  female,  aged  twenty- 
two,  who,  after  presenting  symptoms  of  chronic  obstruction, 
died  after  nine  days  of  somewhat  acute  manifestations.  The 
autopsy  revealed  a  small  and  simple  retrograde  intussus- 
ception of  the  sigmoid  flexure  into  the  descending  colon.  The 
invaginated  layers  were  secured  in  position  by  solid  ad- 
hesions, and  formed  in  the  lumen  of  a  gut  a  species  of 
obstructive  valve.  The  bowel  above  the  impediment  was 
ulcerated. 

Nothnagel  X  quotes  a  case  of  retrograde   intussusception 

*  Contrib.  a  1' Etude  des  Invaginations  de  I'lntest.  grele.  Paris,  1879. 

t  These  de  Paris,  I8o7,  p.  .52. 

j  Die  Erkrankungen  des  Darmes.  Vienna,  1896,  p.  290. 


152 


PATHOLOGY    OF   INTUSSUSCEPTION. 


Slayers- 
5  lasers- 
Slay  em 


r\ 


A 


Fia  57. 


which  lasted  eight  months.     In  this  example  the  descending 
colon  was  invaginated  into  the  transverse  colon. 

A  primary  descending  intussusception  may  be  associated 
with  a  secondary  ascending  one,  the  two  occupying  the  same 
segment  of  the  bowel.  In  such  cases  the 
retrograde  invagination  is  external  tj 
the  layers  that  take  a  descending  direc- 
tion. It  is  extremely  probable  that  such 
secondary  invaginations  depend  upon  a 
flaccid  and  plaited  sheath,  a  fold  of  which 
may  slip  up  between  itself  and  the  in- 
tussusceptum  and  so  produce  the  appear- 
ance described^  (Fig.  57).  It  is  signifi- 
cant that  these  complicated  forms  are 
usually  met  with  in  the  colon.  An  ar- 
rano-ement  of  sheath  that  would  favour 
the  complication  is  shown  in  Fig.  55.  A 
good  example  of  the  cases  now  under  notice  is  reported  in  an 
"  annotation  "  in  the  Lancet.  The  patient  was  a  child,  aged 
six  months,  who  died  with  symptoms  of  intussusception  oc- 
curring after  an  attack  of  diarrhoea.  There  was  at  the 
autopsy  a  double  intussusception  of  the  colon.  The  primary 
invagination  was  downwards  and  was  about  five 
inches  in  length.  The  la3'ers  composing  it  were 
adherent  and  deeply  congested.  The  retrograde 
intussusception  evidently  involved  the  sheath 
after  the  manner  just  described.  It  was  about 
half  the  length  of  the  original  tumour  and  free 
from  all  adhesions.  Thus  the  involved  seg- 
ment showed  from  above  downwards  first  three 
layers  of  bowel,  then  five  layers,  and  again  three 
Fig.  .58.  layers  (Fig.  57).  I  can  find  no  recorded  case  that 
would  support  the  statement  of  some  to  the 
effect  that  a  descending  and  a  retrograde  intussusception 
may  start  from  two  points  of  the  intestine,  remote  from  one 
another,  and  then  by  growing  ultimately  meet  and  inter- 
penetrate one  another. 

Instances  of  double  intussusceptions  are  fairly  common. 
In  these  cases  one  invagination  is  primary,  the  other  is 
secondary.  The  primary  tumour  acts  as  a  foreign  body  in 
the  intestine,  and  leads  to  fresh  infolding  of  the  walls  of 
the  bowel.  The  secondary  invagination  concerns  only  the 
sheath  or  receiving  layer  of  the  primary  tumour.  This 
variety  is  met  with  both  in  the  colon  and  in  the  small 
intestine,  and  in  the  intussusceptions  of  the  dying  as  well 

*  See  Leichtenstern,  loc.  cit.,  p.  612. 


PAirr   PLAYED    BY    THE    MESENTERY. 


153 


as  in  the  obstructive  forms.  It  is  most  usiiall}^  found  in 
the  former  species  of  intussusception.  When  met  with  in 
the  obstructive  invagination  the  secondary  layers  may  or 
may  not  present  adhesions.  Usually  they  are  free.  A  good 
example  of  a  double  intussusception  is  in  the  London  Hospital 
Museum.  It  will  be  obvious  that  such  invaginations  will 
present  hve  layers  of  intestine  instead  of  three  (Fig.  58). 

Cases  of  trijde  intussusception  are  not  so  common.  Here 
also  there  is  a  primary  invagination  and  then  two  secondary 
invaginations,  the  tirst  of  which  involves  the 
sheath  of  the  primary  intussusception.  In 
these  cases  it  will  be  evident  that  the  tumour 
will  present  no  less  than  seven  layers  of  in- 
testine, as  can  be  seen  in  the  annexed  dia- 
gram (Fig.  59).  An  excellent  example  of 
this  variety  is  described  with  great  clearness 
by  Bucquoy."^  It  was  met  with  in  a  male 
patient  aged  twenty-two,  who  died  after 
having   presented   the  symptoms  of  chronic  1/ 

intussusception   for    about  six  weeks.       For 
many   months   preceding   the   onset   of    the 
final  attack  he   had   had   somewhat   similar 
seizures,,  but    of    slighter   character   and    of 
short   duration.      Both    the   terminal  attack 
and   one   of  the  previous   seizures    were  as- 
sociated with  the  appearance  of  a  very  dis- 
tinct  abdominal  tumour.     The  post-mortem 
inspection    revealed   a    triple   intussusception    that   involvetl 
nearly   the   whole   of    the  jejunum.      The    tumour    formed 
was  eleven  and   a   half  inches  long   and  six  inches  in   cir- 
cumference, and  presented  seven  lajers  of  intestine. 


Fio.   59. 


THE    GENERAL    PATHOLOGICAL    CHANGES    IN    AN 
INTUSSUSCEPTION. 

1.  The  Part  Played  by  the  Mesentery.— As  an  in- 
vagination increases  it  is  obvious  that  the  mesentery  must 
be'^drawn  in  with  the  bowel.  In  a  tumour  of  any  magnitude 
it  is  found  between  the  two  layers  of  the  intussusceptum, 
drawn  out  into  the  form  of  a  cone,  with  its  apex  at  the 
extremity  of  the  intussusception  and  its  base  at  the  neck. 
As  the  invagination  increases  the  traction  upon  the  mesentery 
nuist  be  great.  In  cases  of  extensive  intussusception  it  may 
be  well  imagined  that  that  traction  is  often  considerable. 
For  instance,  the  ileum  with  its  mesentery  may  be  inverted 

*  Recuoil  lies  Travaux  do  la  Soe.  Med.  d'Observ.,  p.  192.     Paris,  18.37. 


154  PATHOLOGY    OF   IXTUSSUSGEPTIOy 

into  the  caecum,  and  ma}^  travel  along  the  whole  length  of 
the  colon,  until  it  j)resents  or  even  protrudes  at  the  anus.  It 
is  obvious  that  in  such  cases  the  mesentery  must  be  either 
unduly  long  or  must  have  been  greatly  stretched.  Thus 
in  a  specimen*  of  ileo-ca^cal  intussusception,  in  an  infant  of 
eight  months,  which  reached  the  rectum,  "  the  peritoneum 
covenng  the  left  kidney  was  tightl}^  stretched,  and  the 
stomach  and  duodenum  were  drawn  from  their  usual  situa- 
tion." Dr.  Delepine  records  an  instance  in  which  the 
duodenum  was  dragged  between  the  layers  of  an  ileo-csecal 
invagination  by  reason  of  excessive  traction  upon  the  meso- 
colon. The  specimen  was  obtained  from  the  body  of  an 
infant  of  iive  months,  t  The  increased  length,  however, 
required  in  the  mesenter}*  to  permit  the  appearance  of  the 
intussusception  at  the  anus  is  not  so  considerable  as  may 
at  lirst  sight  appear.  As  the  prolapsed  gut  travels  from 
the  caecum  to  the  anus  it  practically  describes  a  circle.  The 
centre  of  this  circle  may  be  taken  as  the  vertebral  attach- 
ment of  the  mesenter}',  and  the  radii  of  the  circle  as  repre- 
sented by  the  mesentery  itself  The  distance  between  the 
involved  bowel  and  the  mesenterial  centre  is  not  greatly 
increased  as  the  prolapsed  part  passes  along  the  colon.  In- 
deed, the  greatest  demand  upon  the  length  of  the  mesentery 
is  made  bv  the  drag-ginof  ot  the  membrane  into  the  narrow 

Co       o 

tube  of  the  intussusception. 

The  fact  that  an  ileo-csecal  or  ileo-colic  intussusception 
may  be  felt  in  the  rectum  within  comparatively  a  short  time 
of  its  formation  will  show  that  the  elongation  of  the  mesen- 
tery need  not  be  considerable,  even  if  allowance  be  made 
for  congenital  superabundance.  There  is  no  doubt  that 
the  common  congenital  anomaly  in  which  the  whole  colon 
has  a  free  and  extensive  mesocolon  greatly  assists  the  progress 
of  an  invagination. 

The  traction  exercised  by  the  mesentery  has  a  consider- 
able effect  upon  the  tumour.  It  bends  the  intussusception 
so  that  it  becomes  curved  in  outline,  the  concavity  of  the 
curve  being  towards  the  mesenterial  attachment.  Some- 
times the  bending  is  considerable  and  almost  angular,  while 
a  deep  transverse  lold  forms  across  the  concavity  of  the 
cylinder  of  the  intussusceptum.  This  altered  outline  is 
communicated  in  a  much  diminished  form  to  the  investing 
layer,  and  thus  the  whole  tumour  has  a  tendency  to  assume 
a  curved  outline.  The  concavity  of  this  curve  looks  towards 
the  root  of  the  ujesentery.     As  another  result  of  the  traction, 

*  Mus.  Eoy.  Coll.  of  Surgeons,  No.  2710. 
t  rath.  8oc.  Trans.,  1891,  p.  124. 


PART    PLATED    BY    THE    MESENTERY. 


155 


it  happens  that  the  axes  of  the  intussusceptum  and  intus- 
suscipiens  do  not  correspond.  The  former  does  not  Ke  in 
the  axis  of  the  latter,  but  is  placed  eccentrically  nearer  to 
the   mesenteric    border   of  the  bowel.     It   follows  also   that 


Fig.  60. — Intussusception  of  descending  Colon  into  Sigmoid  Flexure. 
There  is  great  thickening  of  tlie  intussusceptum,  especially  on  its  convex  side,     a,  the  sheath. 


the  orifice  of  the  intussusceptum  is  made  to  assume  the 
aspect  of  a  slit,  and  looks  not  so  much  towards  the  lumen 
of  the  bowel  below  as  towards  the  mesenteric  side  of  the 
receiving  layer. 

The  extent  of  these  changes  A^aries  considerably.  They 
may  be  entirely  absent,  especially,  as  Leichtenstern  remarks, 
in  intussusceptions  of  the  middle  part  of  the  ileum.     They 


156  PATHOLOGY    OF   INTUSSUSCEPTIOyf. 

are  perhaps,  best  seen  in  the  invagmations  of  the  ileo- 
ceecal  region. 

In  the  colon  the  mesocolon  may  play  somewhat  the  same 
part  as  the  mesentery.  In  colic  intussusceptions,  however, 
it  is  very  common  to  find  the  various  layers  of  the  mass 
parallel  to  one  another,  the  aperture  in  the  centre,  and 
directed  toAvards  the  central  axis  of  the  gut  below.  On 
the  other  hand,  several  nuiseum  specimens  show  that  the 
intussusceptum  may  be  as  curved  in  a  colic  invagination 
as  it  is  in  any  enteric  form  of  the  affection.  Such  a  speci- 
men is  shown  in  Fi^.  60,"^  where  the  descending^  colon  has 
become  invaginated  into  the  sigmoid  flexure.  As  an 
example  of  a  straight  or  non-curved  intussusception  of  the 
colon,  I  might  cite  a  specimen  in  the  London  Hospital,  t 

Intussusceptions  of  the  rectum  are  all  more  or  less  free 
from   curving. 

2.  How  Obstruction  and  Strangulation  are  Produced. 
■ — Mere  invagination  of  the  bo\vel  need  not  lead  of  necessity 
either  to  strangulation  of  the  involved  part  or  to  complete  or 
even  serious  obstruction  to  the  lumen  of  the  intestine. 

Many  cases  are  recorded  where  the  patients  have  lived 
for  months,  presenting  evidences  of  the  abdominal  disturb- 
ance, and  have  died  without  ever  displaying  the  symptoms 
of  strangulation  or  acute  obstruction  of  the  bowel.  At  the 
autopsies  made  upon  such  patients,  the  intussusception  that 
caused  death  has  often  been  found  to  show  none  but  the 
most  insignificant  structural  changes  and  to  be  periectly 
reducible.  As  one  instance  I  might  quote  a  case  of  Dr. 
Brinton's,  which  concerns  a  man  who  died  of  chronic  intus- 
susception lasting  over  four  and  a  half  months.  The  post- 
mortem revealed  an  ileo-ca^cal  invagination  quite  free  from 
any  gross  local  changes. ;]:  There  is  also  ]\Ir.  Hutchinson's 
oft-quoted  case  of  a  child,  aged  two,  who  had  suffered  from 
chronic  intussusception  for  one  month.  At  the  end  of  that 
time  Mr.  Hutchinson  opened  the  abdomen,  and  readily 
reduced  the  invagination  he  found  therein.  The  patient 
recovered. §  Many  other  examples  could  be  given.  Such 
cases,  however,  are  exceptional.  More  usually  the  conjpres- 
sion  of  the  involved  mesentery  and  the  manner  in  which  it  is 
dragged  upon  lead  to  some  obstruction  of  its  vessels.  The 
veins  would  be  more  especially  involved,  the  return  of  blood 
from  the  inturncd  gut  would  be  prevented,  and  as  a  result 

*  St.  Thomas's  Hosp.  IMuseum,  No.  li,  12. 

t  No.  Ae  47. 

X  Lancet,  vol.  i.,  1863,  p.  409. 

^  Meil.-Chir.  Trans.,  vol.  xx.wii.,  1874. 


HOW    OBSTRUCTION   IS    PRODUOEIJ.  157 

the  intussusception  would  become  engorged  and  swollen. 
The  swelling  is  tirst  noticed  at  the  apex  of  the  invagination 
and  then  in  the  middle  layer.  Later  the  mesentery  itself 
becomes  swollen  and  the  arteries  of  the  intussusceptum 
become  compressed.  It  is  to  be  noted  that  this  interference 
with  the  circulation  is  of  the  very  kind  that  tends  to  produce 
irregular  movements  in  the  intestine.  The  part  indeed  may 
become  strangulated,  and  as  a  result  the  whole  of  the  intus- 
susceptum may  become  gangrenous.  The  intussusceptum 
is,  in  fact,  in  the  position  of  a  knuckle  of  bowel  in  a 
strangulated  hernia. 

Speaking  generally,  therefore,  it  may  be  said  that  patients 
with  intussusception  may  die  of  one  of  two  principal  causes. 
They  may  die  of  strangulation  of  the  bowel  and  its  results,  or 
they  may  gradually  waste  and  die,  worn  out  by  long-continued 
pain  and  sickness  and  other  effects  of  narrowing  of  the 
bowel.  Chronic  cases  very  often  terminate  with  acute 
strangulation. 

The  actual  obstruction  to  the  passage  of  matters  along 
the  intestine  may  be  brought  about  in  many  ways. 

(1)  The  orifice  of  the  intussusceptum  is  rendered  slit-like 
by  the  dragging  of  the  mesentery,  and  may  be  opposed  to  the 
wall  of  the  receiving  layer. 

(2)  The  intussusceptum  may  be  so  bent  or  curved  upon 
itself  as  to  greatly  narrow  the  lumen  of  the  inner  cylinder. 
This  is,  to  some  extent,  shown  in  Fig.  60. 

(3)  The  considerable  thickening  that  the  tunics  of  the 
involved  bowel  undergo,  as  the  results  of  congestion,  exuda- 
tion, and  inflammation,  tends  greatly  to  narrow  the  lumen  of 
the  passage.  So  extreme  may  the  narrowing  from  this  cause 
alone  be  that  it  may  reduce  the  calibre  of  the  central 
canal  to  that  of  a  No.  10  or  No.  12  catheter.  Thus 
when  the  ileo-ceecal  valve  is  involved  in  the  invagination 
that  aperture  may  be  entirely  occluded  by  swelling  of  the 
margins.     (Fig.  61.) 

(4)  The  already  narrowed  passage  may  be  finally  occluded 
by  some  accidental  circumstance.  Thus  Mr.  Gay  mentions  a 
case  of  ileo-csecal  intussusception  where  the  valve  was  found 
to  be  blocked  by  some  undigested  rice.^  In  other  instances 
the  central  canal  has  been  plugged  by  blood  clots.t  In 
certain  cases  the  polyp  that  caused  the  intussusception 
finally  blocked  entirely  its  lower  aperture,^  and  it  has  been 

*  On  Intestinal  Obstruction  by  Invagination.     London,  1862. 
t   Lancet,   vol.  ii.,    1846,  p.  8S  ;    and  Path.   Soc.   Trans. ,  vol.   xxviii.,    1877, 
p.  131. 

X  M.  Fernet;  Bull,  de  la  Soc.  Anat.,  1863,  p.  296. 


15S  FATHOLOOY    OF  INTUSSUSCEPTION. 

said  by  Dr.  Brinton  that  an  obstruction  may  be  produced  by 
a  gangrenous  intussusceptum  after  it  has  separated.* 

3.  How  the  Invagination  Becomes  Irreducible. — This 
is  a  matter  of  extreme  importance  in  the  prognosis.  If  the 
intussusceptum  be  irreducible,  then  cure  by  spontaneous 
reduction  is  impossible,  as  is  also  reduction  by  means  of 
forcible  enemata  or  by  laparotomy.  On  the  other  hand, 
if  the  tunics  of  the  mass  be  glued  together  by  adhesions 
about  the  neck  the  paTts  are  most  favourably  placed  for 
spontaneous  recovery  by  elimination  of  the  gangrenous 
intussusceptum. 

The  irreducibility  very  commonly  depends  upon  adhesions. 
Peritonitis  is  excited  in  the  invaginated  mass,  and  the  serous 
coats  of  the  inner  and  middle  layers  become  glued  together, 
while  more  extensive  adhesions  involving  also  the  external 
coat  may  occur  about  the  neck  of  the  tumour.  The  situation 
of  the  adhesions  varies.  Sometimes  they  are  limited  to  the 
neck  of  the  mass,  at  other  times  to  its  apex,  while  in  a  third 
class  of  case  they  involve  the  whole  length  of  the  inner  and 
middle  layers.  On  the  whole,  the  last-named  are  the  most 
common,  although  adhesions  limited  to  the  neck  of  the 
intussusception  are  probably  the  more  usual  in  acute  cases. 
Adhesions  occurring  only  at  the  actual  apex  of  the  intus- 
susceptum are  certainly  the  least  frequently  met  with. 

In  any  case  the  false  bands  may  vary  from  a  few  insignifi- 
cant fibres  to  a  dense  membrane  closely  binding  together  the 
opposed  layers. 

In  extensive  invaginations  it  is  common  to  tind  the  first 
few  inches  of  the  intussusception  fixed  by  adhesions  while  the 
remainder  is  quite  free.  In  these  cases  it  is  probable  that  the 
adherent  parts  represent  those  first  invaginated,  no  adhesions 
forming  between  the  layers  subsequently  prolapsed.  Thus  it 
happens  that  the  whole  intussusception  can  be  readily 
reduced,  with  the  exception  of  the  last  inch  or  so. 

Of  the  circumstances  that  influence  the  formation  of 
these  adhesions  little  is  known.  Their  appearance  is  most 
uncertain.  They  may  be  absent  in  a  case  which  has 
lasted  for  months  and  present  in  one  of  but  a  few  days' 
duration. 

For  example,  Mr.  Marsh  t  performed  laparotomy  in  a 
case  of  intussusception  fifteen  hours  after  the  onset  of  the 
symptoms.  In  spite  of  the  short  duration  of  the  invagina- 
tion such  firm  adhesions  existed  as  to  make  reduction 
impossible. 

*  Intestinal  Obstruction.     London,  1868. 
t   Lancet:,  vol.  i.,  1891,  p.  368. 


now  THE  INVAGINATION  BECOMES  IRREDUGIBLE.  159 

Mr.  Parker^  i'oiind  an  ileo-co3cal  invagination  in  a  child 
^f  three  months  qnite  irreducible  on  the  fourth  day.  Mr. 
Winter  t  reports  an  acute  case  ending  fatally  in  seven  days. 
The  patient  was  an  infant  of  seven  months,  and  the  in- 
tussusception projected  at  the  anus.  At  the  autopsy  the 
invagination  was  easily  reduced,  and  no  adhesions  of  any 
kind  existed. 

On  the  other  hand  there  are  the  cases  of  Brinton  and 
Hutchinson  already  quoted. 

Carver  X  reduced  an  intussusception  after  laparotomy 
in  a  boy  who  had  presented  symptoms  for  seven  weeks,  and 
Baur  §  points  out  that  an  invagination  may  exist  for  months 
and  no  adhesions  be  produced. 

In  dealing  with  the  course  and  prognosis  of  intussuscep- 
tion I  have  described  a  case  in  which  after  symptoms 
extending  over  many  months  an  ileo-csecal  invagination  was 
found  to  be  still  most  readily  reduced,  there  being  a  complete 
absence  of  adhesions. 

Putting  aside,  however,  exceptional  cases  it  would  appear 
that  the  element  of  time  has  the  most  marked  effect  upon 
this  occurrence.  In  examples  of  chronic  intussusception 
adhesions  are  the  rule.  They  are  present  in  about  80  per 
cent,  ot  the  cases.  In  acute  invaginations  adhesions  are  as 
often  absent  as  present.  Indeed  they  would  appear  to  be 
more  olten  absent  than  present,  for  an  examination  of  nearly 
sixty  recorded  instances  of  the  acute  form  that  I  have 
collected  myself  shows  the  presence  of  adhesions  in  about 
45  per  cent,  only  of  the  cases.  ||  The  earliest  time  for 
the  appearance  of  definite  adhesions  is,  on  an  average,  the 
third  day.  It  is  needless  to  observe  that  recent  adhesions 
ire  very  soft  and  yielding,  so  that  in  acute  examples,  al- 
though false  ligaments  may  exist,  yet  they  need  not,  in 
themselves,  offer  any  serious  obstacle  to  attempts  at  reduction. 

Irreducibility,  however,  may  depend  upon  other  causes 
than  the  results  of  local  peritonitis. 

(1)  The  swelling  of  the  intussusceptum  may  be  so  exces- 
sive as  entirely  to  prevent  reduction.  Very  often  the  swelling 
is  most  marked   near  the  apex,  so  that  the  inner  cylinderj 

*  Clin.Soc.  Trans.,  1888,  p.  244. 

t  J.ancei,  vol.  i.,  1894,  p.  GOO. 

+  Ibid.,  vol.  i.,  1889,  p.  171. 

§   Berliner  klin.  Wochenscfarift,  1892,  p.  879. 

II  These  statistics  include  cases  of  recovery  without  operation  where  the 
reduction  of  the  mass  was  effected  by  artificial  means.  The  figures  are  probably 
fallacious.  Cases  free  frcra  adhesions  are  obviously  the  most  likely  ones  to 
yield  to  treatment,  and  thus  to  be  placed  on  record.  An  examination  of  museum 
specimens  places  the  number  of  cases  where  adhesions  exist  in  a  higher  per- 
centage. 


160 


PATHOLOGT   OF   INTUSSUSCEPTION. 


present  at  their  extremities  a  liiige  knob  that  would  withstand 
all  attempts  to  replace  the  parts.  A  good  example  of  this  is 
afforded  in  Fisf.  61.^ 


Fig.  G1. — Heo-Cfocal  TiitiissusceiDtion  with  great  swelling  of  the  Intussiisceptum. 


(2)  Since  the  swelling  and  thickening  of  the  coats  are 
most  apt  to  affect  the  convexity  of  the  intussiisceptum  it 
happens  that  so  curved  an  outline  is  often  given  to  that 
part  and  so  great  an  alteration  etiected  in  its  density  that. 

*  St.  Thomas's  Hosp.  Museum,  No.  R  8. 


HOW  THE  INVAGINATION  BECOMES  IBBEDUCIBLE.  161 


reduction   is   for    this    reason   also   quite   impossible.       (See 
Fig.    60.) 

(3)  The  invaginated  bowel  may  become  peculiarly  twisted, 
and  may  on  this  account  be  rendered  irreducible.  Thus  Mr. 
Royes  Bell  performed 
laparotom}^  on  the  fifth 
day  in  a  case  of  intus- 
susception. There  were 
practically  no  adhesions, 
yet  the  mass  was  so 
twisted  that  all  attempts 
at  reduction  failed.  In 
this  instance  the  colon 
was  involved."^  In  Fig. 
62,  from  University  Col- 
lege Museum,  a  specimen 
of  a  twisted  intussus- 
ception is  shown  that 
only  implicated  the 
ileum.f 

(4)  In  ileo-colic  in- 
vaginations an  especial 
obstacle  to  reduction  is 
offered  by  the  ileo-C£ecal 
valve,  which  tightly 
grips  the  prolapsed  gut 
and  induces  in  it  a  rapid 
engorgement. 

(5)  When  a  polyp 
exists  at  the  apex  of 
the  intussusceptum,  it 
forms,  when  associated 
with  swellino-  of  the  gut 
above  it,  a  very  definite 
impediment  to  reduc- 
tion. This  is  well  illus- 
trated in  the  specimen 
from  which  Fig.  63  is 
taken.  J 

4.  Changes   in    the 
Gut  Above. — The  bowel 
above    the   intussuscep- 
tion shows  in  acute  cases  no  gross  changes  other  than  those 
of  dilatation   and   consfestion.     In   chronic   forms,   however, 

o 

*  lancet,  vol.  i.,  1876,  p.  12.  f  No.  1176. 

%  Royal  Coll.  of  Surgeons  Museum,  No.  2719. 


Fig.  62. — Intiiseusception  of  Ileum. 
a   intussusceptum. 


162  PATHOLOGY    OF   INTUSSUSCEPTION. 

its  walls   are  usually  liypertropliied,  and  in  some  instances 
tliis  hypertrophy  has  attained  considerable  dimensions. 

Great  fsecal  accumulation  above  the  invagination  is  rare  in 
any  case,  the  lumen  of  the  bowel  being  usually  sufficiently 
patent  to  allow  of  the  passage  of  matters  for  at  least  some 
time.  Ulceration  of  the  intestine  above  the  involved  segment 
is  comparatively  rare,  and  is  somewhat  more  common  in 
chronic  than  in  acute  cases.  Perforation  may  occur  as  the 
result  of  this  ulceration.  In  at  least  two  instances  the  bowel 
above  the  invagination  underwent  spontaneous  rujDture. 
Both  cases,  more  or  less  chronic,  were  in  adult  males. 
In  one  example"^  the  ileum  had  ruptured  above  an  ileo-caecal 
invagination  ;  in  the  otherf  the  rent  was  found  in  the  middle 
of  the  ascending  colon,  the  intussusception  being  limited  to 
the   rectum. 

5.  Changes  in  the  Intussuscipiens. — The  sheath  or 
receiving  layer  seldom  shows  any  gross  changes.  It  may  be 
congested  or  a  little  thickened.  It  may  be  much  wrinkled 
and  thrown  into  many  folds.  It  may  be  the  seat  of  some 
local  peritonitis.  Such  morbid  conditions  are  common. 
Among  the  less  frequent  changes  may  be  noted  the  follo\ving. 
The  sheath  may  be  greatly  thickened,  j  In  a  case  reported 
by  Hauf,  the  thickness  of  the  three  la3^ers  of  a  chronic" 
intussusception  amounted  to  one  inch.§  This  layer  not 
infrequently  presents  ulcerations  of  its  mucous  membrane, 
which  are  often  multiple  and  ma}^  lead  to  perforation,  or  a 
part  of  the  wall  of  the  sheath  may  become  gangrenous.  This 
local  gangrene  is  often  due  to  the  pressure  of  a  greatly  curved 
intussusceptum,  and  after  it  has  occurred  that  part  may 
protrude  through  the  hole  formed  in  the  sheath.  An 
excellent  example  of  such  protrusion  is  shown  in  Fig.  64.  Ij 
{See  also  Fig.   62.) 

In  a  case  of  acute  intussusception  of  the  ileum  reported 
by  Mr.  Morris,  there  was  extensive  gangrene  of  the,  sheath  on 
the  sixth  day  with  a  threatening  perforation  in  three  or  four 
places.lf  A  like  case  is  reported  by  Dr.  Turner.  The  invag- 
ination was  ileo-colic,  and  the  csecum,  which  formed  the  sheath, 
was  extensively  ulcerated  and  gangrenous  in  places.  The 
patient,  a  boy  of  eleven,  died  on  the  tenth  day."^^  An  in- 
stance of  chronic  intussusception  has  been  placed  on  record 

*  Grissole;  Bull,  de  la  Soc.  Anat.,  1835,  p.  71. 
t  Holmes  ;  Path..  Soc.  Trans.,  vol.  viii.,  p.  77. 

I  London  Hosp.  iluseum,  No.  Ae  45. 

§  Heidelb.  Med.  Annal.,  1842,  b.  8,  s.  428. 

II  Univ.  Coll.  Museum,  No.  1175. 

il  Path.  Soc,  Trans.,  vol,  xxviii.,  p.  131. 
**  Path.  Soc.  Trans.,  1881,  p.  83, 


CHANGES    IN    THE    INTUS8USCEPTUM.  163 

where  the  sheath  was  entirely  ruptured  and  divided  into  two 
distinct  parts,  one  of  which  contained  the  intussusceptum, 
while  the  other  was  empty."^ 

Perforations,  which  may  occur  either  in  the  sheath  or  in 
the  gut  above  the  intussusception,  are  a  little  more  frequent 
in  chronic  than  in  acute  cases.     Out  of  fifty-five  examples  of 


Fig.  63. — lutussusception  of  the  Ileum. 


A  firm  oval  tumour  exists  at  tlie  eud  of  the  intussusceptum.    A  bougie  indicates  the 
lumen  of  the  gut. 

chronic  intussusception  collected  by  M.  Rafinesque,t  there 
were  twelve  instances  of  perforation.  Among  one  hundred 
and  seventy-five  cases,  both  acute  and  chronic,  Leichtenstem 
found  twenty-eight  examples  of  perforation.  This  compli- 
cation is  most  common  in  the  ileo-c^cal  forms  and  least 
common  in  the   ileo-colic. 

6.  Changes  in  the  Intussusceptum. — The  cyhnders  in- 
volved become  engorged  with  blood,  and  haemorrhages  may 
occur  in  their  substance  or  from  their  surfaces.  It  is  from  the 
latter  source  that  is  derived  the  bleeding  which  is  so  often  a 
conspicuous  feature  in  intussusceptions,  especially  those  of 
an  acute  character.  The  walls  may  become  rapidly  cede- 
matous  and  greatly  swollen,  and  the  condition  run  on  readily 

*  Journ.  cle  Med.  cle  Sedillot,  tome  50,  1814,  p.  446. 
t  These,  Paris,  1878, 


164  PATHOLOGY    OF   INTUSSUSCEPTION. 

to  gangrene.  The  microscopic  changes  which  occur  in  the- 
walls  of  the  invaginated  bowel  have  been  fnlly  investigated 
and  described  b}^  Mr.  D'Arc}'    Power. ^ 

In  more  chronic  cases  great  thickening  of  the  layers  of 
the  intussusceptum  may  be  met  with  as  the  result  of  long- 
continued  congestion  and  insidious  inflammation  of  a  low 
type.  In  both  acute  and  chronic  cases  the  thickening  of  the 
laji^ers  may  be  equally  distributed  throughout  the  involved 
cylinders,  but  more  usually  it  is  most  conspicuously  marked 
in  two  places,  viz.  at  the  apex  of  the  intussusceptum  (see 
Fig.  61),  and  along  its  convexity.  (See  Fig.  60.)  Swelling 
can  most  conveniently  occur  in  these  places,  since  these 
parts  of  the  intussusceptum  are  the  most  free  from  pressure. 
Along  the  concavity  of  a  very  curved  tumour  much  cedema 
would  be  impossible,  the  layers  there  being  thrown  into 
tightly  arranged  folds  and  greatly  pressed  upon.  It  must 
also  be  noted  that  the  convexity  of  the  involved  bowel  is  the 
part  most  remote  from  the  entrance  of  the  intestinal  vessels, 
and  is  thus  the  more  likelj^  to  be  first  to  show  evidences- 
of  vascular  disturbance.  For  identical  reasons,  earlj^  engorge- 
ment may  be  expected  at  the  apex  of  the  mass  when  con- 
striction at  the  neck  is  prominently  marked.  The  swelling 
and  thickening  about  the  apex  lead  to  the  knob-like  tumour- 
which  ofters  so  great  an  obstacle  to  reduction.  It  is  also  the 
soft  swelling  at  the  extreme  end  of  the  intussusceptum  which 
gives  to  that  part  the  appearance  and  the  response  to  the 
touch  of  the  os  uteri  with  which  it  has  been  so  many  times 
compared.  In  both  acute  and  in  chronic  cases  the  middle 
cylinder  suffers  more  and  shows  more  advanced  changes 
than  does  the  inner  cylinder.  Thus,  when  there  is  much 
thickening  of  the  intussusceptum,  it,  as  a  rule,  mosth' 
concerns  the  middle  layer.  The  thickness  of  this  layer 
may  be  considerable.  In  one  case,  recorded  by  Mr.  Sidney 
Jones,  the  width  of  the  wall  of  the  middle  cylinder  varied 
from  one-third  to  one-half  of  an  inch.t  The  intussusception 
had  existed  for  nine  weeks. 

The  inner  cylinder  or  entering  laj^er  is  often  greatly 
contracted,  a  circumstance  which  may  be  met  with  m  both 
acute  and  chronic  cases.  Thus  in  one  acute  case  this  cylinder 
was  found  to  be  no  larger  than  the  iliac  artery.  The  in- 
vagination involved  the  ileum,  and  occurred  m  a  patient 
thirteen  years  of  age.1: 

One  of  the  most  important  and  most  constant  changes  in. 

*  Journ.  of  Fath.  and  Bad.,  June.  1897,  p.  484. 
t  Path.  Soc.  Trans.,  vol.  viii.,  p.  179. 
X  Ibid.,  vol.  xxviii.,  p.  131. 


CHANGES    IN    THE    INTUSSUSOEPTUM.  165 

tlie  intussusceptum  is  gangrene.  This  condition  is  met  with 
in  both  acute  and  chronic  cases,  although  it  is  always  more 
common  and  usually  more  extensive  in  the  former.  The 
intussusceptum  has-been  found  to  be  quite  gangrenous  as 
■early  as  the  third  day.'^     It  may  involve  the  whole  mass  of 


Fig.  64. --Intussusception  of  the  Ileum.     Protrusion  of  tlie  Intussusceptum 
through  an  ulcerated  Opening  in  the  Sheath. 

a,  upper  end  of  involved  gut;   t,  lower  end  of  involved  gut;   o,  the  protruding 
intussusceptum. 

the  intussusceptum,  which  may  separate  at  the  neck  and 
be  discharged  from  the  bowel.  This  occurs,  as  a  rule,  in 
acute  invao-inations,  althouo-h  it  is  sometimes  met  with  in 
chronic  cases  which  end  acutely.  The  gangrenous  part 
eliminated  may  vary  in  length  from  a  few  inches  to 
several  feet.  Cruveilhier  has  recorded  an  instance  where 
three  metres  of  bowel  were  discharged  by  this  process.     The 

*  Parker ;  Clin.  See.  Trans.,  1888,  p.  244. 


166 


PATHOLOGY   OF   INTUSSUSCEPTION. 


gangrene  usually  appears  first,  and  remains  most  advanced 
m    the    middle    layer.      Thus    it    happens    that    when    the 

separation  of  the  intussus- 
ceptuni  occurs  the  middle 
cylinder  may  be  disin- 
tegrated, and  in  some  parts 
missing,  while  the  enter- 
ing layer,  although  dead, 
may  still  be  sufficiently 
well  preserved  to  show  the 
structure  of  the  bowel. 
Sometimes  the  anatomical 
details  of  the  part  are 
singularly  well  preserved 
in  the  separated  intestine. 
An  example  of  this  is 
afforded  by  a  specimen 
in  Guy's  Hospital"^  show- 
ing the  csecum  and  the 
whole  of  the  ascending 
colon,  which  were  passed 
on  the  eleventh  day,  the 
patient  recovering. 

In  the  Royal  College  of 
Surgeons  Museumt  is  a 
specimen  showing  ten  to 
eleven  inches  of  the  colon 
together  with  a  complete 
vermiform  appendix.  This 
piece  of  bowel  was  passed 
per  rectum  in  a  lad  of 
eighteen,  who  made  a  per- 
fect recovery  from  acute 
intussusception. 

Another  specimen  in 
the  same  museum  J  shows 
no  less  than  forty  inches  of 
the  ileum  which  were  passed 
per  anum.  At  the  end  of 
this  portion  of  bowel  is  a 
polyp  half  an  inch  long. 
The  patient  was  a  lad}^  of 
thirty-two.  The  intestine  was  voided  eighteen  days  after 
the  commencement  of  severe  symptoms  of  intussusception. 
The  case  ended  in  recovery,     (Fig.  65.) 

*  No.  1875.  t  No.  2714.  t  No.  2715. 


Fig.  65. — Portion  of  the  Small  Intestine, 
40  inches  long,  voided  per  anum  as  a 
slough,  the  result  of  Intussusception. 
(Royal  Coll.  of  Surg.  Mus.,  No.  271o.) 


GANGRENE    OF    THE    INTUSSUSGEPTU3L 


167 


In  a  case  of  acute  intussusception  recorded  by  Dr. 
O'Connor*  over  eleven  inches  of  the  ileum  with  a  Meckel's 
diverticulum  attached  were  passed  per  anum  eight  days 
after  the  onset  of  symptoms.  The  patient,  a  boy  of  thirteen, 
made  a  good  recovery.     (Fig.  66.) 

Sometimes  the  mner  cylinder  is  more  extensively  involved 
in  the  gangrenous  process  than  is  the  middle  layer.  This 
condition  is  usu- 
ally met  with  in 
ileo-c£ecal  invag- 
inations, where 
the  part  of  the 
intussusceptum 
formed  by  the 
small  intestine 
may  perish  before 
the  segment 
formed  by  the 
large.  The  matter 
of  an  interval  of 
time  between  the 
separation  of  the 
inner  and  middle 

layers    mav    atfect    ^^^-  ^^- — Slough  of  the  ileum.,  with  a  Meckel's  diverti- 
.T*'  n/,.  ,.  culum,    passed    after    acate    intussusception.     (Dj: 

the     condition     Ot  O'Connor's  case.) 

the  gilt  as  it  ap- 
pears when  discharged  from  the  anus.  This  can,  however, 
only  concern  intussuscepta  which  are  free  from  adhesions. 
Suppose  that  in  the  invagination  (Fig.  67,  a)  separation 
takes  place  along  the  transverse  hue  b,  and  that  the  two 
cylinders  are  adherent,  it  is  obviously  a  matter  of  indif- 
ference, as  regards  the  appearance  of  the  discharged  mass, 
which  layer  separates  first.  The  cylinder  which  first  comes 
away  will  have  to  wait,  as  it  were,  for  its  fellow,  and 
they  will  then  be  discharged  together,  retaining  the 
mutual  relations  which  existed  between  them  before 
gangrene  set  in.  Suppose,  how^ever,  that  no  adhesions 
exist,  and  that  the  middle  cylinder  separates  first,  as  is  most 
usual  (Fig.  67,  b),  the  separated  layer  may  immediately  unfold 
itself,  and  when  the  inner  cylinder  is  set  free  the  dead 
gut  will  be  discharged  as  one  continuous  tube,  with  its 
serous  covering  external  and  its  lumen  lined  by  mucous 
membrane. 

If,  however,  the  inner  layer  is  set  free  before  its  fellow 
(Fig.  67,  c),  it  may  become  unfolded,  and  when  the  separation 

*  Brit.  Med.  Journ.,  vol.  ii.,  1894,  p.  123. 


!.( 


PATHOLOGY    OF   INTUSSUSCEPTION. 


M 


is  complete  the  gangrenous  bowel  will  be  passed  as  a 
continuous  tube,  but  with  its  mucous  layer  external  and 
with  its  lumen  lined  with  the  serous  coat.  In  such  cases 
(and  many  examples  have  been  reported)  the  gut  is  said 
to  have  been  passed  "  turned  inside  out."  Authors  who 
describe  these  cases  are  apparently  under  the  impression 
that  the  process  of  "  turning  inside  out "  is  effected  in  the 

dead  gut  as  it  passes  along  the 
intestine.  This,  however,  is  not 
only  difficult  to  understand,  but 
is  supported,  as  far  as  I  can  as- 
certain, by  no  evidence  of  any 
kind.  I  have  already  said  that 
cases  marked  by  more  advanced 
gangrene  of  the  entering  layer 
belong  to  the  ileo-csecal  type  of 
invagination,  and  it  is  only 
among  examples  of  this  type 
that  1  have  been  able  to  find 
instances  of  gangrenous  intes- 
tine passed  with  its  walls  turned 
inside  out.^ 

In  some  instances  one  of  the 

cylinders  alone  may  be  separated 

as    a    definite    tube,    the   other 

away   in   the    form    of 


U 


fT 


y 


rr 


UP 


Mi  M 


commsr 


gansfrenous  shreds. 


B 


C 


Fig.  67. 


In  another  set  of  cases,  which 
as  a  rule  belong  to  the  chronic 
form  of  the  malady,  the  gan- 
grene commences  at  the  apex  of 
the  intussusceptum.  It  may  remain  confined  to  this  part, 
producing  but  limited  destruction.  This  is  ilhistrated  by  a 
case  recorded  by  Rafinesque  where  the  ileo-csecal  valve 
which  formed  the  point  of  the  intussusceptum  was  the 
only  part  destroyed.  More  usually,  however,  it  spreads, 
and  the  invaginated  mass  perishes  slowly,  and  is  eliminated 
in  shreds  and  putrid  fragments  which  may  pass  unrecognised. 
In  one  case  of  chronic  invagination  where  the  parts  were 
becoming  gangrenous,  the  inner  and  middle  layers  presented 
a  rent  which  permitted  the  intestinal  contents  to  pass  be- 
tween the  intussusceptum  and  the  intussuscipiens.f 

*  A  good  example  of  this  apj)arently  inverted  bowel  is  given  by  Dr.  Fagge  in 
his  monograph  in  the  Guy's  Hospital  Reports.  Dr.  Fagge  thinks  that  the 
process  of  "  turning  inside  out  "  goes  on  during  the  expulsion  of  the  gangrenous 
and  inert  mass. 

t  Lhonneur  and  Vulpian  ;  Bull,  de  la  Soc.  Anat.,  1855,  p.  100. 


GANGRENE    OF    THE    INTUSSUSCEPTUM.  169 

In  the  least  marked  form  of  the  destructive  process  the 
mucous  membrane  is  alone  involved.  This  membrane  may 
be  gangrenous  in  part  or  be  ulcerated,  the  morbid  changes  in 
any  case  being  as  a  rule  limited  to,  or  most  marked  at,  the 
apex.  Such  mild  forms  are  much  more  common  in  chronic 
than  in  acute  cases. 

Speaking  generally,  then,  it  may  be  said  that  in 
acute  invaginations  gangrene  is  more  common  and  more 
extensive,  that  it  involves  principally  the  neck  of  the 
mass,  and  is  associated  with  an  elimination  of  the 
cylinders  more  or  less  in  their  entirety.  In  the  chronic 
forms  the  gangrene  is  less  rapid,  is  most  marked  at 
the  apex,  and  leads  usually  to  a  slowly  progressing 
destruction  whereby  the  intussusceptum  is  eliminated  in 
frao'ments. 

Among  less  common  and  less  important  changes  in 
the  intussusceptum  the  following  may  be  mentioned. 
The  inner  and  middle  layers  may  alter  their  mutual 
positions  after  the  invagination  has  formed.  This,  I  think, 
is  demonstrated  by  those  cases  where  a  polyp  is  associated 
with  the  intussusception,  but  where  it  is  found  some  way 
up  upon  the  returning  layer  instead  of  at  the  apex  of  the 
tumour. 

The  mucous  membrane  may  be  densely  pigmented  in 
some  chronic  cases  as  a  result  of  long  -  abiding  con- 
gestion."^ 

Katinesque  has  collected  one  or  two  cases  of  chronic 
intussusception  where  .soft  and  scant}^  adhesions  existed 
between  the  mucous  surfaces  of  the  sheath  and  of  the 
returning  layer. 

Lastly  may  be  noticed  the  association  of  ejyithelioma  with 
certain  cases  of  chronic  intussusception  of  the  colon.  In 
most  of  the  recorded  cases,  and  in  most  museum  specimens, 
the  epitheliomatous  growth  has  been  found  upon  the  apex  of 
the  intussusceptum.  In  such  instances  there  is  very  little 
doubt  but  that  the  growth  preceded  the  invagination.  It  is 
very  certain,  however,  that  the  neoplasm  may  grow  after  the 
intussusception  has  formed.  The  specimen  from  which  Fig. 
68 1  has  been  taken  shows  the  internal  layer  of  an  ileo-csecal 
invagination  enormously  thickened  b}^  a  peculiar  deposit. 
This  deposit  on  examination  proved  to  be  composed  of 
the  tissue  of  a  cylindrical  epithelioma.  The  specimen  was 
obtained  from  the  body  of  a  man,  aged  fifty-six,  who  had 
presented   symptoms   of  chronic   intussusception   for   about 

*  As  an  example,  see  lancet,  vol.  v.,  1863,  p   409. 
t  University  College  Museum,  No.  5-592. 


170 


PATHOLOGY   OF   INTUSSUSCEPTION. 


twelve  months  before  his  death.  He  was  under  the  care  of 
Mr.  Christopher  Heath,  who  reheved  the  patient  for  a  little 

while  by  establishing  an  arti- 
ficial anus."^  The  lumen  of 
invaginated  ileum  is  greatly 
reduced  in  size.  The  neoplasm 
has  invaded  mainly  the  con- 
vex surface  of  the  intussus- 
ceptum,  involving,  however, 
both  surfaces  of  the  apex  of  the 
protrusion. 

The  growth  along  the  con- 
vexity of  the  intussusceptum 
has  been  evidently  influenced 
by  the  lesser  degree  of  pressure 
exercised  upon  that  part  of  the 
mass.  It  is  not  improbable 
that  in  this  case  the  cylindroma 
commenced  at  the  ileo-csecal 
valve,  and,  acting  as  a  foreign 
substance,  produced  the  invag- 
ination, and  then  continued  to 
develop  in  the  direction  offering 
the  least  resistance. 

A  specimen  in  the  Royal 
College  of  Surgeons  Museum,t 
dejDicted  in  Fig.  69,  shows  an 
intussusception  immensely 
thickened  by  a  morbid  growth 
which  involves  the  whole  cir- 
cumference of  the  mucous 
membrane.  The  free  surface  is 
flocculent  and  ulcerated.  The 
new  growth  proved  to  be 
cylindrical-celled  cancer  under- 
ffoinCT  colloid  degeneration. 
The  patient,  a  woman  of  fifty, 
had  present  the  evidences  ot 
chronic  intussusception. 

The  association  of  cancer 
with  intussusception  as  cause 
and  effect  is  dealt  with  on  page  183,  and  reference  may  be 
made  to  Figs.   68  and  69. 

*  An   a  ccount  of   the   case   will   be   found  in   the  Registrar's  Eepoits  of 
University  Coll.  Hosp.  for  1881,  p.  27,  case  No.  84. 
t  No.  2718. 


Fig.  68.  —  Chronic  Intussuscep- 
tion with  Epithelioma  of  the 
Internal  Layer. 

A  bougie  occupies  the  lumen  of  the 
intestine. 


ETIOLOGY    OF   INTUSSUSCEPTION. 


171 


THE    ETIOLOGY    OF    INTUSSUSCEPTION. 

1.  The    Immediate    Cause. — Many   theories    have   been 
advanced  to  explain  the  invagination  of  one  portion  of  the 


Fig.  69.  —Section  of  an.  Intussusception. 

The  invaginated  bowel  is  greatly  thickened  by  a  new  growth  (cylindrical-celled  cancer). 
{Royal  Coll.  of  Surg.  M\is.,  Xo.  271S.) 


intestine  into  another.  Some  of  these  have  not  withstood 
the  test  of  time,  while  others  are  too  vague  and  too  in- 
definitely expressed  to  "be  susceptible  of  criticism.  "With 
such  theories,  and  with  the  discussions  to  which  they  have 
given  rise,  I  propose  to  have  no  concern:   but  will  consider 


172  PATHOLOGY   OF   INTUSSUSGEPTION. 

merely  the  one  explanation  "which,  I  venture  to  think,  has 
in  it  the  greatest  element  of  truth. 

There  is  practically  unanswerable  evidence  to  show  that 
hitussusception  is  brought  about  b}''  irregular  action  in  the 
muscular  wall  of  the  intestine. 

The  precise  nature  of  that  irregularity  may  be  a  matter 
open  to  some  question.  So  far  as  the  facts  at  present  at 
our  disposal  would  show,  it  would  appear  that  an  intus- 
susception occurs  either  at  a  point  where  the  gut  is  the 
seat  of  a  limited  and  severe  muscular  contraction,  or  at  a 
point  where  a  paralysed  segment  joins  a  part  still  capable 
of  vigorous  contraction.  Thus  had  arisen  the  division  of 
intussusceptions  into  two  forms,  the  invaginatio  spasmodica 
and  the  invaginatio  paralytica. 

The  chief  data  in  connection  with  this  subject  have  been 
furnished  by  the  elaborate  experiments  of  Nothnagel,^  of 
which  some  account  may  now  be  given.  The  intestines  of 
a  rabbit  having  been  exposed  with  suitable  precautions,  a 
segment  of  the  bowel  is  stimulated  by  means  of  a  faradic 
current  applied  through  electrodes  placed  so  close  together 
that  a  perfectly  circumscribed  ring-like  contraction  is  pro- 
duced. On  increasing  the  current,  a  contraction  follows, 
which  extends  for  a  considerable  distance  upwards,  i.e. 
towards  the  stomach,  but  only  for  a  very  slight  extent 
downwards.  The  gut  at  the  point  of  stimulation  is  by  this 
time  converted  into  a  perfectly  pale  hard  cord  from  con- 
traction of  the  circular  muscle.  Proceeding  upwards,  the 
contracted  segment  is  found  to  pass  either  gradually  into 
the  normal  intestine  or  to  end  quite  abruptly.  In  the  latter 
instance  a  minute  intussusception  forms.  The  wide  tube 
of  the  normal  gut  above  slides  a  little  over  the  contracted 
part  below.  Thus  is  formed  a  retrograde  intussusception. 
Such  invaginations,  however,  are  always  very  small,  show 
no  tendency  to  increase,  and  are,  indeed,  of  only  momentary 
duration.  Proceeding  downwards  from  the  point  of  stimu- 
lation a  very  difterent  condition  is  met  with.  A  proper 
descending  invagination  is  found  to  be  forming.  On  closely 
examining  its  mode  of  development,  these  points  are  to  be 
noticed.  The  spot  at  which  the  electrodes  are  applied  forms 
practically  a  fixed  point.  The  normal  gut  immediately  below 
the  contracted  part  turns  itself  upwards  to  a  slight  extent 
over  this  strongly  contracted  and  greatly  narrowed  portion. 
A  minute  invagination  is  thus  produced,  which  increases 
solely  at  the  expense  of  the  intussuscipiens. 

This  mode  of  development  is  clearly  demonstrated  by  the 

*  Beitriige  zur  Physiologie  und  Pathologie  des  Cannes,  p.  42  ;  Berlin,  1884. 


ETIOLOGY   OF   INTUSSUSCEPTION. 


173 


following  experiment.  In  Fig.  70  the  condition  of  the  gut  at 
the  time  of  the  experiment  is  shown,  c  is  the  upper  end  {i.e. 
towards  the  stomach),  d  is  the  lower  end,  and  e  is  the 
contracted  segment.  At  one  spot  a  on  the  bowel  a  fine 
blue  thread  was  drawn  through  the  serous  coat  and  then 
cut  short.  At  another  point  b  lower  down  a  red  thread 
was  in  like  manner  introduced.  The  electrodes  were  applied 
at  the  point  a,  represented  by  the  blue  thread 
An  ascending  contraction  e  of  the  bowel  followed,  ^ 

while  below  the  point  of  stimulation  an  invagina- 
tion formed.  During  the  development  of  this 
intussusception  the  electrodes  remained  unmoved 
at  a,  and  the  blue  thread  kept  always  at  the 
upper  retiring  angle  or  neck  of  the  invagination. 
The  red  thread,  however,  moved  gradually  up- 
wards until  it  reached  the  upper  retiring  angle, 
wlien  it  disappeared.  After  a  while,  when  the 
intussusception  was  cut  open,  the  red  thread  was 
found  about  the  middle  of  the  middle  layer. 

The  invaginations  so  produced  existed  for  a 
certain  length  of  time,  and  then  disappeared  as 
the  gut  became  restored  to  its  normal  condition. 

Nothnagel  found  that  stimulation  of  the  bowel 
above  the  intussusception  had  no  effect  in  pro- 
moting its  unfolding,  while  stimulation  ot  the 
intussuscipiens  merely  caused  the  invagination 
to  become  all  the  more  rigid.  Stimulation,  how- 
ever, of  the  gut  below  the  involution  caused  an  t^ 
ascending  contraction,  by  means  of  which  the  i'-"^-  "O- 
intussusception  was  at  once  relieved. 

Thus,  in  one  case  where  an  mvasfination  of  the  colon  had 
been  artificially  produced,  it  was  made  to  disappear  by  an 
antiperistalsis  induced  by  an  enema  of  a  solution  of  conamon 
salt. 

The   experiments   described   so   far   refer   to   invaginatio 
spasmodica.      Nothnagel's    investigation   of  the 
paralytica  give  the  following  results. 

A  segment  of  bowel  from  three  to  six  inches  in  length 
"was  entirely  paralysed  by  crushing.  When  stimulation  was 
applied  above  the  paralysed  part  nothing  followed  save  the 
usual  ascending  contraction.  When,  however,  the  electrodes 
were  applied  to  the  gut  immediately  below  the  inert  segment 
a  typical  descending  intussusception  developed.  This  in- 
vagination grew  solely  at  the  expense  of  the  normal  bowel. 
The  paralysed  part  was  not  concerned  in  it,  the  electrodes 
remaining  quite  unmoved  at  the  original  place  of  application.. 


174  PATHOLOGY    OF  INTUSSUSCEPTION. 

just  as  occurred  in  the  previous  experiment  at  the  mark  of 
the  bkie  thread. 

These  researches  serve  to  demonstrate,  so  far  as  they  go, 
the  existence  of  both  a  spasmodic  and  a  paralytic  form  of 
intussusception.  Nothnagel  considers  that  the  former  variety 
is  mfinitely  more  common  than  the  latter,  and  the  evidence 
afforded  by  clinical  observation  would  support  his  opinion. 

The  distinction  between  these  two  forms  is  not  of  material 
importance.  The  simple  fact  remains  that  intussusception 
depends  upon  irregular  action  in  the  muscular  Avail  of  the 
intestine. 

There  are  but  few  clinical  facts  to  support  the  existence 
of  a  paralytic  form  of  invagination  of  the  type  described  by 
Nothnagel.  It  may  perhaps  be  considered  for  the  present 
as  a  laboratory  affection.  The  part  played  by  irregular 
muscular  action  is  further  illustrated  by  the  fact  that  when 
the  intestines  of  a  rabbit  are  merely  exposed  it  is  possible 
now  and  then  to  note  frequent  minute  intussusceptions 
forming  and  dissolving. 

The  experiments  detailed  should  serve  to  correct  some 
common  impressions  which  exist  as  to  the  production  of 
invao-ination,  and  which  are  still  expounded  in  certain  text- 
books. There  is  no  driving  of  a  contracted  segment  of  gut 
into  the  non-contracted  part  below  by  the  "  propulsive  action 
of  the  intestine."  Peristalsis  in  the  bowel  above  the  con- 
tracted portion  appears  to  have  no  influence  in  the  formation 
of  the  intussusception ;  and  it  is  a  question  rather  of  one 
piece  of  gut  being  drcavn  over  another  than  of  one  part 
being  thrust  into  the  subjacent  segment.  As  some  writers 
have  expressed  it,  the  contracted  gut  is  swallowed  by  the 
non- contracted  bowel  below  it.  It  is  important  also  to  note 
that  the  whole  length  of  the  contracted  segment  is  not  used 
in  the  invagination,  as  is  often  assumed. 

I  do  not  think  that  sufficient  importance  has  been 
attached  to  the  action  of  the  longitudinal  layer  of  muscle 
in  producing  intussusception,  although  Nothnagal  makes 
some  mention  of  the  probable  part  it  plays. 

If  the  arrangement  of  parts  be  considered  in  that  area 
of  the  bowel  where  a  vigorously  contracted  segment  joins  a 
non-contracted  portion,  the  condition  of  the  muscle  of  the 
intestine  will  be  as  follows  :  The  action  of  the  circular  layer 
must  cease  abruptly  at  the  line  v/here  the  contracted  and 
non-contracted  parts  meet,  since  the  fibres  of  this  layer  are 
placed  at  right  angles  to  the  long  axis  of  the  gut.  The  action 
of  the  longitudinal  fibres  must  extend,  however,  beyond  the 
Ime   of   meeting.      If  they  be  considered  to   act  from  the 


ETIOLOGY   OF   INTUSSUSCEPTION.  175 

contracted  segment  as  from  a  fixed  point,  it  is  evident  that 
they  will  tend  to  draw  the  wide  non-contracted  segment  over 
the  narrow  and  contracted  piece.  In  this  way,  by  the  drawing 
of  one  part  of  the  intestinal  tube  over  another  part,  the 
intussusception  is  formed,  and  this  mode  of  formation  applies 
as  well  to  the  retrograde  as  to  the  descending  invaginations. 

When  once  the  invagination  has  taken  place,  it  is  probable 
that  the  intussusception  acts  the  part  of  a  foreign  body  in  the 
intestine,  stimulates  the  intussuscipiens  to  contract  and  so 
force  along  the  inturned  cylinder. 

Clinical  facts  strongly  support  the  association  of  intus- 
susception with  disordered  intestinal  movements.  Con- 
spicuous are  the  attacks  of  colic,  which  are  so  early  and 
so  marked  a  sign  of  the  condition  ;  the  frequent  association 
of  the  intussusception  with  states  attended,  or  apt  to  be 
attended,  by  disturbed  peristaltic  movements,  'such  as 
diarrhoea,  intestinal  polypi,  the  presence  of  masses  of  un- 
digested food  in  the  bowel,  cancer  of  the  intestinal  wall, 
and  the  like.^ 

Intussceptions  have  been  met  with  in  cases  where  a  cause 
of  grave  intestinal  disturbance  already  existed.  Thus  Mr. 
Joseph  Bell  reports  a  case  of  strangulation  by  band,  for  the 
relief  of  which  he  performed  laparotomy.  On  opening  the 
abdomen,  he  discovered  an  invagination  of  the  bowel,  four 
inches  in  length,  which  was  readily  reduced.t  The  occur- 
rence of  intussusception  after  injury  to  the  abdomen  may 
depend  upon  some  local  disturbance  in  the  activity  of  the 
intestine  resulting  from  the  lesion.  In  some  few  instances 
intussusceptions  have  occurred  after  typhoid  fever,  after 
cholera,  after  severe  enteritis,  and  after  the  reduction  of 
strangulated  hernia,  all  being  conditions  under  which  dis- 
ordered intestinal  action  may  be  expected. 

It  may  be  noted  also  that  invaginations  are  most  common 
in  the  young,  in  whom  nerve  processes  are  active,  in  whom 
the  bowel  is  more  irritable,  and  in  whom  the  tissues  are 
susceptible  of  ready  change  and  capable  of  being  easily 
disturbed. 

The  "  invaginations  of  the  dying,"  moreover,  are  most  apt 
to  occur  in  those  who  have  died  of  some  grave "  nerve  lesion, 
such  as  meningitis,  and  in  whom  it  may  not  be  unreasonable 
to  expect  a  disturbance  of  so  important  a  part  of  the  nervous 
system  as  that  supj)lying  the  intestines.     (See  page  148.) 

And  here,  by-the-bye,  I  might  venture  to  suggest  that 

*  Griesenger  has  shown  that  in  dysentery  a  paralysis  of  a  section  of  the 
intestine  is  not  uncommon. 

t  Udin.  Med.  Joicrn.,  1882,  p.  63. 


176  PATHOLOGY   OF   INTUSSUSCEPTION. 

slight  invaginations  having  a  more  or  less  momentary  exist- 
ence are  probabl}^  much  more  common  in  the  human  subject 
than  is  supposed.  It  seems  to  me  there  is  good  reason  for 
believing  that  some  attacks  of  colic,  especially  such  as  follow 
upon  the  ingestion  of  unassimilable  food,  may  have  for  their 
anatomical  basis  a  series  of  temporary  invaginations  of  the 
Trowel. 

The  resemblance  between  these  colicky  attacks  and  an 
attack  of  intussusception  appears  to  be  often  peculiarly  com- 
plete, and  the  divergence  between  the  two  sets  of  cases  to 
depend  simply  upon  the  element  of  duration  or  persistence. 
In  both  there  is  the  same  kind  of  pain,  the  same  disposition 
to  vomit,  the  same  form  of  constitutional  depression,  and 
often  the  common  symptom  of  marked  tenesmus.  When 
the  invagination  becomes  strangulated,  the  resemblance  of 
course  ceases.  It  is  difficult  to  avoid  the  belief  that 
many  of  the  cases  of  protracted  "  spasms "  met  with 
in  delicate  women,  and  in  persons  liable  to  digestive  dis- 
turbances, are  due  to  definite  intussusceptions,  which  in  time 
reduce  themselves  instead  of  passing  on  to  strangulation.  The 
sudden  onset  of  these  attacks,  their  equally  sudden  cessation, 
and  the  manner  in  which  they  yield  to  opiates,  appear 
strongly  to  support  this  belief. 

The  peculiarly  frequent  occurrence  of  invaginations  in 
the  ileo-csecal  region  requires  some  slight  explanation.  This 
frequency  may  depend  to  some  extent  upon  the  difference 
in  size  between  the  ileum  and  the  colon,  and  the  ease  with 
which  the  former  could  be  prolapsed  into  the  capacious 
csecum. 

At  birth  it  is  true  that  the  colon  is  only  a  few  millimetres 
greater  in  diameter  than  is  the  small  intestine,  but  at  the  age 
of  puberty  the  colon  is  from  two  and  a  half  to  three  times 
as  large  as  the  ileum  which  enters  it. 

Facilities  for  invagination,  moreover,  are  offered  by  the 
fixed  position  of  the  csecum  as  compared  with  the  mobility 
of  the  lower  ileum,  and  by  the  circumstance  that  at  the 
valve  of  Bauhin  an  active  segment  of  the  bowel  meets  a 
comparatively  inert  portion. 

Leichtenstern  and  others,  however,  have  pointed  out  the 
great  influence  that  the  sphincter-like  valve  may  have  in 
producing  invaginations.  They  have  compared  the  ileo-csecal 
orifice  to  the  anus,  and  the  intussusceptions  of  this  region  to 
prolaj)se  of  the  rectum.  The  matter  cannot  be  better  ex- 
pressed than  in  Leichtenstern's  own  words.  "  If  we  consider 
that  the  ileo-ca3cal  opening  is  distinguished  by  a  sphincter, 
the  contraction  of  which  can  increase  to  powerful  tenesmus. 


ETIOLOGY   OF   INTUSSUSCEPTION.  177 

we  recognise  that  there  is  a  coiiiplete  analogy  between  the 
conditions  of  invagination  in  the  region  of  the  csecuni  and 
the  different  kinds  of  prolapse  of  the  rectum,  which,  like  ileo- 
cascal  invaginations,  is  found  most  frequently  in  early  child- 
hood. Just  as  anal  tenesmus,  excited  by  any  cause  whatever 
(rectal  blennorrhoea,  profuse  diarrhoea),  usually  excites  and 
accompanies  prolapse  of  the  rectum,  so  is  ileo-csecal  tenesmus, 
excited  by  catarrh  or  abnormal  irritability  of  the  terminal 
portion  of  the  ileum,  of  great  importance  in  the  production 
of  many  ileo-ca^cal  and  ileo-colic  invaginations.  In  many 
cases  in  which  we  see  invaginations  in  the  region  of  the 
cascum  follow  prolonged  diarrhcea  or  colic,  the  taking  of 
unsuitable  food,  or,  especially  in  early  infancy,  the  withdrawal 
of  the  mother's  milk  and  the  substitution  of  improper  food, 
csecal  tenesmus  plays  an  important  part.  If  the  csecum  and 
the  colon  are  rendered  easily  movable  by  their  mesentery,  as 
is  regularly  the  case  during  early  life,  the  repeated  and  more 
forcible  peristaltic  pressure  towards  the  persistently  contracted 
ileo-csecal  sphincter  causes  ileo-ctecal  mvagination.  If  the 
csecum  be  firmly  fastened  down,  so  that  it  cannot  be  turned 
in  and  invaginated  into  the  colon,  prolapse  of  the  ileum  into 
the  colon  takes  place,  with  formation  of  an  ileo-colic  invagina- 
tion, just  as  prolapse  of  the  rectum  may  follow  violent  anal 
tenesmus.  If  neither  of  these  happens,  invagination  of  the 
lowest  part  of  the  ileum  may  occur,  as  is  the  case  also 
in  the  rectum  when  it  becomes  invaginated  in  itself 
above  an  obstinately  contracted  (tenesmus)  sphincter, 
and  is  finally  prolapsed.  If  ileo-csecal  invaginations  are 
very  common  in  children,  and  ileum  invaginations,  on 
the  contrary,  ver}^  rare,  the  reason  lies  in  the  greater 
mobility  of  the  csecum  and  ascending  colon  allowed  by 
their  mesentery,  and  the  consequent  removal  of  an 
obstacle  to  invagination.  In  adults  this  element  is  not 
removed,  and  we  find  ileum  invaginations  as  frequent  as 
ileo-csecal."  "^ 

2.  The  Remote  or  Exciting-  Cause.-^A  great  deal  has 
been  written  upon  the  question  of  the  exciting  causes  of 
intussusception,  and  stress  laid  upon  the  circumstance  that 
with  a  more  perfect  knowledge  of  these  causes  a  more  definite 
form  of  prophylactic  treatment  may  be  attempted.  Precise 
knowledge  upon  this  point,  however,  is  still  wanting.  From 
an  examination  of  a  number  of  reported  cases,  and  from 
certain  statistics  bearing  upon  the  matter  of  etiology,  it  is 
probable  that  in  100  examples  of  intussusception  the  exciting 
causes  would  be  distributed  as  follows  : 

*  Loc.  cit.  Ziemssea's  Cyclopaedia,  vol.  vii.,  p.  617. 
M 


.178  FATEOLOGY   OF  INTUSSUSCEPTION. 

1.  No  evident  exciting  cause     .         .        .         .         .52  per  cent. 

2.  Diarrhoea,  dysentery,  enteritis,  marked  irregu-  ]        „ 

larity  of  the  boAvels i  " 

3.  Polypi  and  diverticula 8        „ 

4.  Ingesta    ....>....  15         „ 

5.  Injuries  and  exposure  to  cold      ....  5        „ 

6.  Certain  acute  and   chronic  ailments  which  may 

or  may  not  have  had  a  concern  in  the  etiology, 
such  as  typhoid  fever,  whooping  cough,  cholera, 
and  hernia  ;  with  these  may  be  included  cancer     12        „ 

Total    100 

Some  more  detailed  notice  m.ay  be  taken  of  tlie  circum- 
stances to  be  considered  under  these  six  headings. 

(1)  It  would  appear  that  in  more  than  half  of  the  cases 
which  have  been  recorded  no  cause  could  be  found  for  the 
invagination.  It  is  probable  that  this  percentage  is  too  high, 
since  in  many  of  the  cases  coming  under  this  heading  the 
evidence  is  negative,  the  patient's  previous  condition  not 
having  been  detailed.  Leichtenstern,  how^ever,  out  of  a  total 
of  593  cases  found  no  less  than  111  in  which  it  was  distinctly 
stated  that  the  trouble  ap23eared  abruptly  in  patients  enjoying 
at  the  time  perfect  health. 

Wiederhofer  maintains  that  most  cases  of  intussusception 
in  children  occur  when  the  child  is  in  perfect  health. 

In  reading  through  a  collection  of  well-recorded  cases  one 
cannot  but  be  struck  with  the  great  frequency  wdth  which 
invaginations  have  appeared  in  persons  of  delicate  health. 
Many  are  simply  described  as  delicate,  others  as  wasted, 
several  have  been  anjemic,  and  not  a  few  have  been  the 
subject  of  heart  disease  or  of  chronic  pulmonarj^  mischief."^ 

If  an  impaired  state  of  health  has  any  real  concern  in 
the  production  of  intussusception,  then  such  a  state  may 
possibly  explain — in  part  at  least — the  instances  which 
have  been  ascribed  to  pregnancy,  measles,  scarlet  fever  and 
small-pox. 

(2)  Probably  the  cases  coming  under  this  heading  are  re- 
presented, on  the  other  hand,  by  too  low  a  figure.  The 
association  of  intussusception  with  diarrhcea  is  marked, 
although  in  some  instances  I  think  the  purging  has  been 
rather  a  symptom  of  the  disease  than  the  cause  of  it. 
Possibly  in  many  cases  of  chronic  diarrhcea  in  children, 
where  the  purging  suddenly  ceases  some  little  ^vhile  before 
death,  and  Avhere  the  mothers  are  apt  to  say  that  "the  child 

*  For  marked  examples  see  Path.  Soc.  Trans.,  vol.  xxiv.,  p.  108  (anaemia)  ; 
ibid.,  vol.  xxxii.,  p.  82  (heart  disease) ;  and  Bull,  de  la  Soc.  Anat.,  1867,  p.  136 
(chronic  phthisis). 


ETIOLOGY    OF   INTUSSUSCEPTION''.  179 

was  purged  until  tlicre  Avas  nothing  more  to  pass,"  there 
may  be  an  intussusception  present  to  account  for  the  altered 
circumstances  of  the  case. 

Intussusceptions  presumably  due  to  diarrhrea  are  most 
commonly  met  with  in  children,  and  are  most  often  of  the 
colic  or  ileo-cffical  varieties."^  In  one  or  two  cases  an  intus- 
susception has  appeared  after  the  administration  of  powerful 
aperients. 

(3)  An  example  of  the  association  of  an  intussusception 
with  polyp  is  shown  in  Fig.  63.t  Tiie  polj^p  is  usually  found 
attached  to  the  apex  of  the  intussusceptum,  although  in  rare 
cases  it  may  be  found  about  its  middle,  owing  probably  to 
a  shifting  of  the  entering  and  returning  laj^ers.  In  some 
examples  the  association  is  no  doubt  accidental,  as  was 
probably  the  case  in  a  specimen  described  by  Sir  Prescott 
Hewett,  where  a  pedunculated  polyp,  the  size  of  a  pear,  was 
attached  to  the  intussuscipiens  just  below  the  invagination. J 

Mr.  Lockwood  §  reports,  on  the  other  hand,  an  example 
in  which  the  polyp  was  situated  entirely  above  the  in- 
tussusception. 

The  polypi  in  these  cases  vary  in  size  from  a  hazel  nut 
to  an  eg^  or  a  pear.  As  a  rule,  however,  they  are  quite 
small.  They  are  oval,  usually  pedunculated  and  nearly 
always  attached  to  the  convex  wall  of  the  intestine.  In 
two-thirds  of  the  cases  they  are  found  attached  to  the  lower 
ileum,  and  thus  they  most  frequently  lead  to  enteric,  or  to 
ileo-c?ecal,  or  ileo-colic  invaginations.  They  have  produced 
intussusceptions  in  the  jejunum, ||  the  duodenum,^  the  colon 
and  the  rectum.  They  more  usually  produce  acute  than 
chronic  forms  of  the  malady.  As  a  rule,  only  one  polyp 
is  found  associated  with  the  invaoination.  Dr.  Fuller,  how- 
ever,  records  a  case  where  thirty  of  such  tumours  were  found, 
with  the  largest  of  which  an  intussusception  was  involved.^^ 
In  one  remarkable  instance  three  polypi  at  some  distance 
apart  caused  three  separate  intussusceptions  in  the  same 
patient.    The  three  tumours  formed  were  visible  during  life.tt 

Fig.  71  shows  an  intussusception  of  the  rectum  clue  to  a 
growth  which  projects  into  the  bowel.     In  several  instances 

*  For  marked  examples,  see  Lancet,  vol.  i.,  1876,  p.  12 ;    Path.  See.  Trans., 
vol.  viii.,  p.  177  ;  St.  Bart.'s  Hosp.  Reports,  1876,  p.  9o. 

t  See  also  specimens  in  Lond.  Hosp.  Museum,  No.  Ae  45,  and  Eoyal  Coll.  of 
Surgeons  Museum,  No.  2719. 

X  Path.  Soe.  Trans.,  vol.  i.,  p.  95. 

§  Ibid.,  1892,  p.  74. 

i|   Ibid.,  1890,  p.  121. 

•1   Bull,  de  la  Soc.  Anat.,  1864.  p.  37. 
**  Path.  Soc.  Trans.,  vol.  xxi.,  p.  188. 
t+  Bull,  de  la  Soc.  Anat.,  1870,  p.  260. 


180 


PATHOLOGY   OF   INTUSSUSCEPTION. 


an  intussusception  has  been  apparently  induced  by  a  Meckel's 
diverticulum.  Dr.  Adams*  described  a  case  in  whicb  an 
inverted  Meckel's   diverticulum   three  inches  in  length  was- 

involved  in  an  ileo- 
colic intussuscep- 
tion. The  patient 
was  a  man  aged 
forty-two,  and  the 
symptoms  were  sub- 
acute. 

A  specimen  in 
Gu3"'s  Hospital 
Museum  t  shows  a 
short  Meckel's  diver- 
ticulum which  had 
become  inverted  so 
as  to  project  into 
the  lumen  of  the 
ileum  and  had 
caused  an  intussus- 
ception. Fig.  72  is 
from  a  specimen  m 
the  Royal  College  of 
Surgeons  Museum,  j 
It  shows  a  Meckel's 
diverticulum  an 
inch  and  a  half  long- 
which  had  become 
mvaginated  into  the 
ileum  and  had  led 
to  an  intussuscep- 
tion. 

Mr.  Golding" 
Bird§  reports  a 
remarkable  case  in 
a  child  of  four  weeks 
old,  in  which  a 
Meckel's  process  opened  at  the  umbilicus.  The  diverticulum 
became  prolapsed  at  the  navel,  and  through  this  prolapsed 
tube  an  intussuscepted  piece  of  ileum  emerged.  The  ileum 
belonged  to  the  gut  below  the  origin  of  the  diverticle. 
Earth  11  describes  a  similar  case. 


Fig.   71. — ^Vertical  Section  of  Bladder  and   Kectum, 
showing  an  Intussusception  of  the  Eectum  due  to  a 
Growth,  which  projects  from  the  Bowel  WalL 
{Royal  Coll.  of  Surg.  Mv.s.,  Ko.  2722.), 


*  Path.  Soc.  Trans.,  1892,  p.  75. 
t  No.  1819^.  X  Xo.  2718^ 

§  Clin.  Soc.  Trans.,  1896,  p.  32. 
II  Deutsche  Zeitsch.  f.  Chir.,  1887. 


INTUSSUSCEPTION    OF    THE    APPENDIX.  181 

Allied  to  the  invaginations  associated  with  an  inverted 
Meckel's  diverticulum  are  the  examples  of  intussusception 
of  the  appendix.  A  good  instance  is  reported  by  Mr,  B. 
Pitts,"^  in  which  the  vermiform  appendix  became  inverted, 
projected  into  the  bowel  and  produced  an  ileo-c^ecal  in- 
tussusception (Fig.  73). 

In  a  case  of  intussusception  of  the  appendix  leading  to 
an  ileo-csecal  invagination  reported  by  Mr.  Waterhouse,t 
the  swollen  appendix  formed  a  globular  mass  three-quarters 
of  an  inch  in  length  and  two  and  an  eighth  inches  in  cir- 
cumference. I  have  met  with  a  very  similar  case  in  a  girl 
of  twelve,  in  which — being  convinced  that  the  mass  pro- 
jecting into  the  csecum 
after  the  reduction  of 
the  ileo-csecal  invagina- 
tion was  a  tumour — 1 
excised  the  swelling. 
It  proved  on  examina- 
tion to  be  an  enormously 
thickened  invaginated 
appendix.  It  measured 
two  inches  on  its  long 
axis,  and  its  transverse 
diameter,  as  measured 
after  section,  was  one 
inch  and  a  quarter. 
The  symptoms  of 
chronic  intussusception 

.  ^          1      '  .   1  1            ,  Fia.  72. — Invagination  of  a  Meckel's  Diverticulum. 

An     aClniiraDle     ex-  Tlie  process  projected  into  the  ileum  and  led  to 

ample  of  chronic  intUS-  a  fatal  intussusception. 

SUSC  option        of       the  (.Royal  Coll.  of  Surg.  Mus  ,  'tJo.  271Sa.) 

appendix    into     the 

csecum  is  reported  by  Messrs.  Wright  and  Renshaw.J  The 
child  was  aged  two  years  and  ten  months,  the  symptoms  had 
existed  one  month  when  the  child  was  successfully  relieved 
by  operation.  The  condition  had  been  suspected  to  be  due 
to  tuberculosis  of  the  mesenteric  glands. 

Other  examples  of  intussusception  of  the  appendix  have 
been  reported.  § 

Dr.    Rolleston||    reports    a   case    in    which   the   mucous 

*  Lancet,  June  12,  1897. 
t  Path.  Soc.  Trans.,  1898,  p.  108. 
i  Brit.  Med.  Journ.,  June  12,  1897. 

§  McGraw;    Brit.  Med.  Journ.,  vol.   ii.,  1897,  p.  956.     J.  McKidd;  Edinh. 
Med.  Journ.,  1859.     W.  Chaffey ;  lancet,  1888  ;  quoted  by  McGraw. 
(I  Edin.  Med.  Journ.,  July,  1898. 


182 


PATHOLOGY   OF   INTU8SU8GFPTI0K 


coat  alone  of  the  vermiform  appendix  was  prolapsed  for 
half  an  inch  into  the  ceecum.  In  the  prolapse  was  a 
concretion. 

(4)  The  severe  colic  often  produced  during  the  passage  of 
undigested  food  through  the  intestine  suggests  that  masses 
of  such  matters  may  frequently  cause  invagination.  A  good 
example  of  this  association  is  shown  in  a  specimen  in 
University  College  Museum.'^"  The  specimen  is  from  the 
small  intestine  of  an  animal,  and  it  will  be  seen  that  the 
invagination  has  formed  itself  about  a  large  piece  of  un- 
digested tendon.  In  a  case 
recorded  by  M.  Le  Moyne  it  is 
supposed  that  a  mass  of  partly 
digested  beans  found  at  the 
autopsy  in  the  sigmoid  flexure 
had,  during  its  passage  through 
the  intestine,  produced  no  less 
than  six  invaginations,  which 
Avere  found  after  death.t  In  a 
patient  of  M.  Dubois' :[:  the  symp- 
toms appeared  soon  after  swallow- 
ing a  number  of  cherry  stones. 
Max  Baur  mentions  a  case  in 
which  the  symptoms  of  intussus- 
ception followed  upon  the  eating 

Fro.  73.— Invagination  of  the  Vermi-  of  a  quantity  of  chcrrics  together 
form  Appendix.  with  their  stones.§ 

A,  the  invaginatecl  appendix ;  b,  depres-  Ty.     +>,p     poop    nf    a      littlp     oirl 

sion  in  csecum  at  attachment  of  the  ^'^^     ^^^^     ^"^^^    ^^     ^      ULUiO     gUi 

appendix ;  0,  ileum.  {Mr.  Pitts' case.)    upOU    whom  I  Operated  for    intUS- 

susception  I  found  a  mass  of 
chewed  nuts  in  the  bowel  close  to  the  invagination.  In  a 
case  by  Mr.  Gay||  a  mass  of  rice  was  found  in  the  intussus- 
ceptum,  and  other  instances  of  this  association  of  undigested 
food  masses  with  invagination  have  been  given  with  equal 
clearness. 

(5)  The  relation  between  injuries  and  invaginations  is,  it 
must  be  confessed,  not  very  clear.  The  intestinal  trouble  has 
appeared  after  blows  upon  the  abdomen,  after  a  patient  has 
been  ridden  over,  and  after  severe  compression  of  the  belly. 
Three  or  four  examples  have  been  given  where  the  symptoms 


*  No.  1170. 

t  Contrib.  a  TEtude  des  Invaginations.     Paris,  1 879-.     These. 
t  Gaz.  des  Bop.,  1863,  p.  298. 

§  Berlin,  klin.  Wochen.,  1892,  p.  817.     Sec  also  a  case  of  Leichtenstern's 
Deutsch.  Archiv.  f.  klin.  Med.,  1874,  p.  381. 
II  Monograph,  loc.  cit. 


ETIOLOGY    OF   IXTUSSUSCEPTION.  183 

of  invagination  developed  suddenly  while  the  child  was  being 
"jumped"  in  someone's  arms."^ 

It  has  followed  upon  sudden  and  severe  muscular  move- 
ments,t  has  occurred  after  gymnastic  exercises,^  and  after 
the  violent  coughing  of  whooping  cough.  §  Leichtenstern  gives 
an  instance  in  which  intussusception  appeared  to  be  chie  to 
massage  of  the  abdomen  applied  to  relieve  constipation.  The 
intussusception  of  the  jejunum  depicted  in  Fig.  54  came  on 
immediately  after  chloroform  narcosis  for  osteotomy.  The 
patient  died  in  ten  days. 

Leichtenstern  has  collected  six  cases  where  the  symptoms 
appeared  after  exposure  to  cold.  In  a  solitaiy  instance  the 
evidences  of  invagination  came  on  shortly  after  drinking  much 
cold  water  while  sweating.  In  the  Lancet  for  1867  is  recorded 
the  case  of  a  child,  aged  iive,  who  died  in  four  days  from  the 
effects  of  a  burn.  For  the  last  forty-eight  hours  of  its  life 
there  had  been  stercoraceous  vomiting.  The  autopsy  revealed 
three  invaginations :  two  were  recent,  but  the  third  had 
evidently  existed  for  some  little  time.  || 

(6)  Under  this  heading  it  is  impossible  to  assign  any 
detinite  position  in  the  etiology  of  intussusception  to  the 
various  maladies  that  are  mentioned.  Not  infrequently  the 
association  has  probably  been  purely  casual  Thus  Vierhoif^"' 
gives  an  account  of  intussusception  occurring  during  an  attack 
of  purpura. 

In  other  mstances  the  debility  produced  by  the  previous 
ailment  has  probably  been  an  influential  factor  in  the 
causation  of  the  disorder  in  the  bowels.  In  those  examples, 
however,  where  invaginations  have  followed  upon  cholera  and 
hernia,  it  may  be  allowed  that  a  morbid  state  of  the  bowel 
had  been  induced  which  would  readily  lead  to  intussusception. 

Among  the  rarer  causes,  real  or  apparent,  of  invaginations 
may  be  mentioned  stricture  of  the  ileo-ctecal  valve,  growths  of 
different  kinds  attached  to  the  valve,  ft  and  malignant  affections 
of  the  intestine.  Growths  Avhich  produce  intussusceptions 
are,  as  a  rule,  innocent.  Such  growths  are  free  and  often 
polypoid.  Carcinoma  of  the  bowel,  on  the  other  hand,  tends 
to  make  the  intestinal  tube  rio-id  and  to  fix  it  to  neiolibourino- 
parts, 

*  Rilliet  and  Barthez ;  Traite  clinique  et  prat,  des  jMal.  des  Enfants, 
1861,  t.  i.,  ID.  806.  Lancet,  vol.  i.,  1877,  p.  273.  Sew  York  Med.  Record, 
1896,  p.  73. 

t  Lancet,  vol.  ii.,  1888,  p.  315. 

i  Ibid.,  vol.  i.,  1893,  p.  651. 

§  Trans.  Clin.  Soc,  1889,  p.  282. 

II    Lancet,  vol.  i.,  1867,  p.  362. 

**  St.  Petersb.  med.  Wochens.,  1893,  p.  320. 

ft  Dance;  Arch.  Gen.  de  Med.,  1832,  p.  177. 


184 


PATHOLOGY   OF   INTUSSUSCEPTION. 


In  the  museum  of  St.  George's  Hospital"^  is  a  specimen  of 
ileo-csecal  invagination  from  a  cliild.  aged  five  montlis.  The 
csecum  contains  three  growths  about  the  size  of  a  spht  almond, 
which  proved  on  examination  to  be  round-celled  sarcomata. 
I  removed  by  laparotomy  the  bowel  containing  an  ileo-cpecal 
intussusception  of  small  size  and  of  very  chronic  type,  which 

had  associated  with  it  a  lympho- 
sarcomatous  growth  of  the  bowel. 

Actual  carcinoma  of  the  bowel 
is  not  very  aj)t  to  lead  to  intussus- 
ception. In  cancer  of  the  rectum 
there  is  very  often  a  species  of 
prolapse  of  the  bowel,  so  that  the 
cancerous  part  appears  to  project 
into  the  lumen  of  the  gut  like  a 
large  cervix  uteri.  This  condition 
is,  however,  not  true  invagination, 
but  is  the  outcome  partly  of  a 
peculiar  mode  of  growth  and  partly 
of  pressure  from  the  loaded  bowel 
above. 

In  the  museum  of  the  Royal 
College  of  Surgeonst  is  a  specimen 
of  intussusception  of  the  rectum 


-  — B 


Fig.  74. 


-Double  Lateral  Invagin- 
ation. 
A,   the    smaller    invagination  ;     b,   the 
ai)parent 


laraer    invagination  : 


line  of  adhesion ;   D,  nodule  of  cLuc  to  ail  epitheliomatous  Qfrowth 

epithelioma.     The   oowel   was   per-        i   •    -i  •   '-  c  i  ^^        r 

vious  in  front  of  the  invaginations,    WlllCn     prOJCCtS     irom     the    Waii    Ot 


and  also  behind  them,  as  shown  bv    ^i         i  i  "     rni  •  l     j 

the  dotted  line.   (Dr.Dcdton'scoji,!.)  the  Dowei.     ihecasc   IS   rccordcd 

in  the  twenty- third  volume  of  the 
Pathological  Society's  Transactions  (Fig.  71). 

Excellent  examples  of  the  association  of  intussusception 
with  malignant  disease  of  the  colon  are  reported  by  Mayo 
Ptobson  %  and  by  Symonds.§  Bryant  gives  an  account  of 
three  specimens  showing  this  association,  and  also  reports  two 
cases,  in  women  of  the  ages  respectively  of  eighty-four  and 
fifty,  in  which  an  intussusception  of  the  lower  part  of  the 
colon  was  associated  with  "  a  papillomatous  growth  "  attached 
to  the  intussusceptum.  II 

Fig.  74  shows  a  remarkable  case  reported  by  Dr.  Dalton,^^ 
in  which  an  epithelioma  of  the  descending  colon  led  to  a 
double  lateral  invagination  of  the  intestinal    wall 

*  Sec.  9,  No  so,  i. 

t  No.  2722,     See  also  specimens  Nos.  2720  and  2721. 

I  Brit.  Med.  Journ.,  vol.  ii.,  1895,  p.  963, 
§    Ibid.,  vol.  i.,  p.  638. 

II  Med.-Chir.  Trans.,  1894,  p.  169. 
**  Path.  Soc.  Trans.,  1890,  p.  122. 


185 


CHAPTER  VII. 

OBSTPtUCTIOlNT  DUE  TO  FOREIGN  BODIES,  GALL  STONES, 
AND  ENTEEOLITHS. 

1,  Foreign  Bodies. — By  a  "foreign  body"  as  applied  to 
tlie  intestinal  tract  is  meant  any  substance  tliat  can  resist 
the  digestive  action  of  the  fluids  of  the  stomach  and 
bowels. 

These  substances  may  be  swallowed  by  accident,  or 
during  fright,  or  they  may  be  taken  intentionally.  It 
would  appear  that  in  several  instances  swindlers  endeavour- 
ing to  pass  false  coin  have  swallowed  the  spurious  pieces 
to  escape  detection.  Some  of  these  foreign  substances  have 
been  swallowed  with  suicidal  intent.  A  great  many  of  the 
reported  cases  have  occurred  in  the  persons  of  lunatics  and 
in  the  subjects  of  hysteria.  In  not  a  few  instances  the 
substance  has  slipped  down  the  throat  during  sleep  or  un- 
consciousness from  anaesthesia,  and  this  especially  applies 
to  false  teeth. 

These  foreign  bodies  may  be  conveniently  divided  into 
three  classes :  (1)  Rounded  or  regularly-shaped  substances 
which  may  be  considered  capable  of  passing  readily  through 
the  intestine.  Among  such  are  pebbles,  stones,  fruit  stones, 
coins,  bullets,  Murphy's  buttons,  and  the  like.  (2)  Sharp- 
pointed  bodies  and  substances  of  irregular  shape  which  may 
readily  catch  in  the  mucous  membrane  or  are  of  an  outline 
that  would  favour  their  becoming  fixed  m  the  aliinentary 
passages.  Such  are  pins,  needles,  hooks,  plates  carrying 
false  teeth,  pieces  of  bone,  pieces  of  metal  or  of  porcelain, 
nails,  screws,  and  other  such  substances,  many  of  which  have 
been  frequently  found  in  the  intestine  or  have  passed  through 
it.  (3)  Indigestible  materials  of  small  size  which  are  apt 
to  accumulate  until  they  form  huge  masses.  Indeed,  the 
largest  foreign   substances   found  in    the    alimentarj^   canal 


186 


OBSTRUCTION   DUE    TO    FOREIGN   BODIES. 


Fig.  7'5. — Vulcanite  Tooth-plate, 
swallowed  by  a  young  girl  and 
passed  per  anum  in  forty-two 
hours.     Natural  size. 

(Royal  GoU.  of  Surg.,  Miis.    No.  2,440). 


liave  been  of  this  character.  They  are  composed  of  husks 
of  the  oat,  vegetable  fibres,  grape  skins,  or  of  hairs,  or  of 
wool  or  yarn.  The  last-named  materials  have  either  been 
swallowed  as  a  matter  of  habit  by  dressmakers  and  others, 

or  have  been  intentionally  taken 
by  lunatics  and  hysterical  indi- 
viduals. 

There  is  no  doubt  but  that  the 
majority  of  the  foreign  substances 
that  are  swallowed  are  in  time 
passed  by  the  anus. 

Nothnagel^  alludes  to  a  case  in 
which  there  were  found  in  the 
evacuations  of  a  lunatic,  during 
the  course  of  eight  months,  157 
pieces  of  glass,  the  longest  being 
6  cm.  long,  102  portions  of  brass 
pins,  150  nails,  three  hairpins,  fifteen  fragments  of  iron  and 
other  foreign  substances. 

A  specimen  in  the  Royal  College  of  Surgeons  Museum  t 
relates  to  the  case  of  a  boy  of  sixteen  who  swallowed  fifty- 
three  marbles  for  a  wager.  They  could  be  heard 
rattling  in  his  abdomen.  Forty-six  of  the 
marbles  were  passed  next  day,  and  the  remain- 
ing seven  on  the  day  after. 

Most  of  the  foreign  bodies  placed  in  the  first 
of  the  above  classes  would  be  evacuated  in  the 
course  of  a  few  days,  or  even  after  twenty-four  or 
forty-eight  hours.  Others  would  be  retained  for 
a  week  or  a  fortnio-ht,  or  lonsrer,  without  causing 
inconvenience. 

The  rate  at  which  the  foreign  substance  may 
pass  through  the  alimentary  canal  is  not  always 
to  be  estimated  by  the  size  and  shape  of  the 
body. 

For  example,  the  vulcanite  tooth-plate  shown 
in  Fig.  75J  was  swallowed  by  a  young  girl  after 
a  fit  of  coughing,  and  passed  per  anum  forty- 


FiG.  76.— A 
Glass  Drop 
of  a  Lustre 
swallowed  by 
a  boy  six  years 
of  age  and 
passed  per 
anum  in  fif  ty- 
two  hours. 
Natural  size. 

{Royal  Coll.  of  Surg. 
J.'/ws.,  No,  2444). 


the    slightest 


two  hours  afterwards  without  having  occasioned 


inconvenience.  Yet  from  one  end  of  the 
plate  there  projects  a  sharp  gold  hook.  On  the  other 
hand,  the  glass  drop  of  a  lustre  depicted  in  Fig.  76 §  was 


*  Die  Erkrankungen  des  Darmes.,  Vienna,  1896,  p.  '284. 

t  No.  2441  A. 

J  Royal  Coll.  of  Surgeons  Museum,  No.  2440. 

§  Eoyal  Coll.  of  Surgeons  Museum,  No.  2444. 


OBSTRUCTION   DUE    TO    FOREIGN   BODIES.  187 

swallowed  by  a  boy,  and,  in  spite  of  its  favourable  outline  as 
compared  with  a  plate  with  teeth,  was  not  passed  per  anum 
until  fifty-two  hours  had  elapsed. 

Many  of  the  foreign  bodies  belonging  to  the  second  of  the 
above  classes  have  also  been  passed  with  comparatively  little 
inconvenience.  Some  of  such  bodies  have  lingered  in  the  ali- 
mentary tube  for  weeks,  for  months,  and  even  for  years.  How 
many  of  these  substances  pass  the  pylorus  and  the  ileo-csecal 
valve  must  remain  an  anatomical  mystery.  Thus,  in  the 
Royal  College  of  Surgeons  Museum  is  a  specimen  (No.  2488) 
showing  a  dessert-spoon,  seven  inches  long  and  with  a  bowl 
one  inch  and  a  half  wide,  lying  fixed  in  the  csecum.  The 
spoon  is  quite  unaltered  in  shape  and  had  been  swallowed  by 
a  lunatic.  Mr.  Pollock  quotes  a  case  where  a  plate  carrying 
six  false  teeth  was  swallowed  and  passed  at  the  end  of  three 
days.  In  another  like  instance  where  the  plate  held  together 
four  teeth  the  mass  was  evacuated  per  anum  at  the  end  of  six 
months."^  In  Dr.  Marcet's  celebrated  case  a  sailor  swallowed 
clasp-knives  from  time  to  time  until  he  had,  in  a  period  of  ten 
years,  consumed  thirty-seven  in  all.  Many  of  these  were 
passed  per  anum  entire,  others  in  fragments.t  A  door-key 
was  passed  in  another  case  four  days  after  it  was  swallowed. J 
In  another  instance,  a  piece  of  a  horse- shoe  was  passed  at  the 
end  of  two  months.  §  In  the  intestine  of  one  lunatic  were 
found  three  cotton  reels,  two  bandages  partly  unrolled,  some 
skeins  of  thread,  and  a  pair  of  braces.  Among  other  strange 
substances  that  have  passed  the  whole  length  of  the  aliment- 
ary canal  may  be  mentioned  the  following :  a  pencil-case, 
a  dagger-blade,  a  small  flute,  a  long  breast-pin,  and  a  brass 
buckle. 

When  the  foreign  substance  is  not  passed  ^er  vias  naturales, 
it  is  apt  to  remain  lodged  in  certain  special  parts  of  the  tube, 
viz.  in  the  stomach,  the  duodenum,  the  lower  end  of  the 
ileum,  the  csecum,  or  the  rectum.  Of  all  these  situations,  the 
csecum  is  the  one  in  which  lodgment  is  most  likely  to  take 
place.  In  the  museum  of  the  Royal  College  of  Surgeons  ||  is  a 
specimen  which  shows  the  upper  portion  of  the  duodenum 
distended  and  blocked  by  a  mass  of  pins  which  weighed 
nearly  a  pound.  The  patient,  a  woman  of  forty-one,  died  of 
incessant  vomiting. 

As  a  foreign  body  passes  along  the  canal,  it  may  cause 

*  Holmes's  Sj-stem  of  Surgerj',  vol.  i.,  p.  910,  3rd  ed.     Lond.,  1883. 
t  Med.-Chir.  Trans.,  vol.  xii.,  p.  32. 
X  Lmicet,  vol.  i.,  1870,  p.  757. 
§  Ibid.,  vol.  ii.,  1874,  p.  674. 
II  No.  2379. 


188  OBSTRUCTION  DUE    TO    FOREIGN   BODIES. 

obstruction  at  any  point,  and  that  obstruction  may  prove 
fatal.  The  progress  of  the  larger  and  more  irregular  sub- 
stance is  marked  by  pain,  by  attacks  of  temporary  obstruction 
associated  with  colic,  vomiting,  and  constipation.  In  other 
instances  an  impacted  foreign  body  has  given  rise  to  long- 
continued  symptoms  of  partial  obstruction,  symptoms  which 
may  become  very  chronic  yet  never  severe. 

There  is  plenty  of  evidence  to  show  that  these  bodies  may 
remain  for  Aveeks,  months,  or  years  in  the  stomach  or  in  some 
part  of  the  intestine  without  causing  active  inischief,  but  that, 
when  so  lodged,  they  may  almost  at  any  time  induce  changes 
leading  to  a  fatal  result.  Moreover,  even  when  they  have 
been  long  retained,  they  may  be  safely  discharged  by  the 
natural  passages.  I  have  had  cases  under  my  care  in  which 
a  Murphy's  button  has  been  discharged  after  having  been 
retained  tor  many  months.  In  one  of  Mr.  Pollock's  cases  a 
plate  of  false  teeth  had  been  swallowed,  and  after  remaining 
in  the  stomach  for  ninety-seven  daj^s  was  finally  ejected  by 
vomiting.  Hashimoto^  records  a  case  where  a  tooth-brush 
had  been  extracted  after  fifteen  years'  retention  in  the  stomach. 
It  had  induced  an  abscess.  The  impacted  foreign  substance 
is,  however,  very  apt  to  cause  some  ulceration  of  the  mucous 
membrane. 

Thus  a  specimen  in  the  Royal  College  of  Surgeons 
Museum t  shows  a  caecum  and  ascending  colon  the  seat  of 
numerous  large  and  most  destructive  ulcers.  The  patient,  a 
lad  of  twelve,  had  suffered  for  sixteen  months  from  severe 
pain  in  the  abdomen,  followed  by  vomiting  which  in  due 
course  became  jDcrsistent.  The  abdomen  was  swollen.  The 
patient  became  very  emaciated  and  died  of  exhaustion. 
Imbedded  in  the  ulcers  in  the  caecum  were  five  cherry  and 
damson  stones,  a  piece  of  wood,  and  half  a  small  button. 
Seven  other  fruit  stones  were  found  loose  in  the  bowel. 

The  ulceration  induced  by  a  foreign  body  may  readily  lead 
to  perforation  and  to  fatal  peritonitis.  This  circumstance  is 
illustrated  by  the  remarkable  case  of  the  "  Human  Ostrich."J 
Tlie  patient  was  a  man  of  forty-two  who  had  been  in  the  habit 
of  swallowing  all  sorts  of  foreign  bodies  "  to  gain  a  livelihood." 
He  died  of  perforative  peritonitis.  There  were  two  perfora- 
tions in  the  ileum  caused  by  sharp  foreign  substances.  An 
artificial  intussusception  had  been  produced  by  a  hook  which 
liad  caught  in  the  bowel  wall  and  had  dragged  it  inwards. 

The  terminal  part  of  the  ileum  was  blocked  for  eighteen 

*  ArcMv  f.  klin.  Chir.,  1888,  p.  169. 

t  No.  2442. 

X  Brit.  Med.  Journ.,  vol.  i.,  1804,  p.  963. 


OBSTRUCTION  DUE    TO    FOREIGN  BODIES.         189 

inches  by  foreign  bodies,  of  which  the  subjoined  is  an  in- 
ventory : — 

Forty  pieces  of  cork  (cut  bottle  corks). 

Thirty  pieces  of  doubled  tinfoil. 

Nine  pennies. 

One  iron  ring  (size  of  a  penny). 

Ten  or  twelve  pieces  of  clay  pipe-stems. 

A  leaden  bullet. 

A  rubber  ring  from  a  lemonade  bottle. 

Three  pieces  of  leather  an  inch  square,  string,  cotton,  newspaper. 

A  piece   of   leather,  nine  inches   long,  with   a  stout  hook  at  each 

end  (one  of  these  hooks  had  been  found  in  the  i:)erforation). 
A   piece    of    string   about   a  foot    long,    with    tinfoil    and    corks 

attached. 
A  few  other  smaller  things. 

From  accounts  given  of  other  cases  it  is  evident  that 
some  local  chronic  peritonitis  may  be  excited  in  the  part 
lodging  the  substance,  and  the  gut  may  become  thereby 
narrowed.  Such  narrowing  ma}^  increase  after  the  evacuation 
of  the  body,  and  may  lead  to  obstruction.  According  to 
Leichtenstern,  "  foreign  bodies  give  rise,  more  frequently  than 
gall  or  intestinal  stones,  to  a  constriction  by  cicatricial  bands 
or  chronic  peritonitis,  at  the  spot  where  they  have  remained 
for  a  long  time." 

In  another  class  of  cases  the  ulceration  of  the  mucous 
membrane  leads  to  the  formation  of  a  fistula  through  which 
the  foreign  body  may  be  discharged.  This  fistula  may 
communicate  with  the  exterior.  Thus  in  the  Royal  College 
of  Surgeons  Museum  is  a  specimen  (No.  2445)  from  a  boy, 
aged  eleven,  where  many  cherry  and  plum  stones  which 
had  been  swallowed  were  discharged  through  an  external 
abscess.  Fig.  77  illustrates  a  remarkable  case  in  which  an 
iron  teaspoon,  which  had  been  swallowed  five  weeks  previously, 
escaped  through  the  parietes  having  produced  a  perforating 
ulcer  of  the  colon.^  The  fistula  may  form  between  the 
stomach  and  the  transverse  colon,  or  between  the  ileum  and 
the  colon,  or  even  between  the  coil  lodging  the  foreign  body 
and  the  rectum  or  the  vagina.  By  such  fistulous  channels, 
has  the  substance  been,  after  a  long  interval,  evacuated. 

The  foreign  body  has  even  escaped  through  the  bladder. 
In  a  case  reported  by  Harrison t  a  man  was  troubled  with 
the  escape  of  faecal  matter  and  flatus  from  the  urethra.  In 
due  course  a  portion  of  the  femur  of  a  rabbit  was  discharged 
with  the  urine,  and  after  that  the  escape  of  fsecal  matter- 
ceased,  and  the  patient  made  a  perfect  recovery. 

*  Mr.  Rouse's  case,  lancet,  Sept.  9th,  1893. 
t  Med.  Press  and  C'irc,  vol.  ii.,  1883,  p.  441. 


190 


OBSTRTJCTION   DUE    TO    FOREIGN   BODIES. 


With  regard  to  small  sharp  -  pointed  bodies,  like 
needles,  they  may  readil}^  penetrate  the  intestine  and  work 
their  way  to  the  surface,  where  they  may  be  recognised 
and  removed.  Thus  I  extracted  from  under  the  skin  of 
the  groin  a  needle  which  had  been  swallowed  by  a  child 
some  months  previously. 

The  foreign  bodies  of  the  third  class  that  cause  obstruc- 
tion by  accumulation  may  form  immense  masses.  In  the 
museum  of  the  Eoyal  College  of  Surgeons"^  is  a  mass  of 


Fig.  77. — Passage  of  an  Iron  Teaspoon,  "vrhich  had  been  swallowed  five  weeks 
previously,  from  the  Colon  through  the  Abdominal  Parietes.  (Case  by 
Mr.  Rouse,  lancet,  Sejjt.  9th,  1893.) 

black  human  hair  removed  b}^  operation  from  the  stomach 
of  a  girl  aged  twenty.  The  mass  weighed  5  lb.  and  3  oz. 
The  patient  did  well. 

When  in  the  intestine,  they  may  lead  to  chronic  and  fatal 
obstruction,  or  may  induce  chronic  or  acute  peritonitis.  Thus 
Marshall  mentions  an  occlusion  of  the  duodenum  by  a  pound 
of  puis  which  had  been  swallowed,  t  In  an  instance  quoted 
by  Duchaussoy  in  his  memoir,  the  obstructing  mass  was 
composed  of  seven  hundred  cherry  stones.  In  a  case  recorded 
by  Dr.  Quain  the  mass  consisted  of  four  pounds  of  cocoa-nut 
fibre,  j 

Dr.    Maylard§    gives   an    account   of    a    case    in   which 

*  No.  2381  A. 

t  Med.-Chir.  Trans.,  vol.  xxxv.,  p.  65. 

J  Path.  Soc.  Trans.,  vol.  v.,  p.  145. 

§  The  Surgery  of  the  Alimentary  Canal.     London,  1896,  p.  337. 


OBSTRUCTION    DUE    TO    OALL    STONES.  191 

intestinal  obstruction  was  brought  al:)Out  in  a  woman  of  fifty- 
five  by  eating,  a  large  quantity  of  gooseberry  skins.  I  have 
seen  a  like  condition  follow  the  consumption  of  a  very 
immoderate  quantity  of  nuts. 

The  whole  question  of  foreign  bodies  in  the  alimentary 
canal  has  been  much  simplified  by  the  introduction  of  the 
Rontgen  method.  Many  skiagraphs  have  been  taken  which 
show  the  presence  of  foreign  substances  of  a  metallic  nature 
in  the  alimentary  canal.  The  progress  of  a  Murphy's  button 
can  be  well  followed  by  the  X-rays. 

2.  Gall  Stones. — The  lumen  of  the  intestine  may  be 
obstructed  at  certain  points  by  a  gall  stone  which  has 
entered  it  from  the  gall  bladcler,  and  is  passing  along  its 
way  to  be  discharged  at  the  anus.  In  the  first  place,  how- 
ever, it  must  be  acknowledged  that  in  the  great  majority 
of  cases  the  gall  stone  passes  without  any  clifficulty  along 
the  intestine,  and  without,  indeed,  exciting  symptoms  of 
any  kind.  The  instances  where  obstruction,  whether  tem- 
porary or  permanent,  is  produced  must  be  regarded  as  quite 
rare  and  exceptional,  although  the  gross  number  of  such 
instances  is  not  small.  So  far  as  the  present  subject  is 
concerned,  it  will  suffice  to  say  that  a  gall  stone  may  reach 
the  intestine  by  one  of  three  routes.  It  may  pass  down 
the  common  bile  duct;  it  may  pass  from  the  gall  bladcler 
direct  into  the  duodenum  by  means  of  a  fistulous  tract ; 
and  it  may  pass  in  like  manner  direct  from  the  gall  bladder 
into  the  colon.  "^ 

It  is  needless  to  say  that  a  stone  which  will  pass  along 
the  narrow  and  somewhat  rigid  bile  duct  cannot  expect  to 
meet  with  any  obstruction  in  the  intestine.  Even  the  lumen 
of  the  ileo-caecal  valve  is  many  times  greater  than  is  that  of 
the  common  duct.  But  the  gall  stones  which  cause  occlu- 
sion do  not  enter  the  intestine  by  the  biliary  passage. 
They  enter  by  means  of  a  temporary  fistulous  communica- 
tion between  the  gall  bladder  and  the  duodenum.  In  very 
rare  examples  the  communication  has  been  between  the 
gall  bladder  and  the  colon  at  the  hepatic  flexure.  A  speci- 
men ifl*  Charing  Cross  Hospital  Museum  (No.  864)  illustrates 
this.  Indeed,  it  appears  to  me,  after  examining  a  large 
number  of  cases,  that  at  present  decided  evidence  is  lacking 
which  would  show  that  a  biliary  calculus  which  has  passed 
along  the  bile  duct  is  capable  of  causing  obstruction  sj^mptoms 
when  it  reaches  the  intestine.  In  many  of  the  reported 
cases   of  .this  supposed   accident   the   condition  of  the  gall 

*  Fistulous  communications  between  the  biliary  passages  and  the  duodenum 
are  twice  as  common  as  are  like  communications  with  the  colon. 


192  OBSTRUCTION  DUE    TO    GALL    STONES. 

bladder  is  not  stated.  In  a  case  placed  on  record  by  Dr, 
John  Abercrombie  it  would  appear  that  the  calculus  had 
reached  the  bladder  through  the  duct.  The  patient  was  a 
man,  aged  forty-five,  who  died  of  acute  obstruction  lasting 
five  days.  He  had  had  previous  obstructive  attacks.  In  the 
ileum  was  impacted  a  gall  stone  measuring  four  inches  in 
its  largest  circumference  and  three  and  a  half  in  its  least. 
The  common  duct  easily  admitted  a  finger.  Then  in  the 
account  comes  the  following  statement,  which  serves  to 
throw  some  doubt  upon  the  mode  of  entrance  of  the  stone  : 
"  The  gall  bladder  was  in  a  state  of  inflammation  and  was 
softened  and  partially  disorganised.""^ 

As  to  the  size  of  the  calculus  that  may  cause  occlusion 
it  must  be  noted  that  stones  of  considerable  dimensions 
have  been  spontaneously  evacuated.  Thus  calculi  have 
passed  the  anus  measuring  two  and  a  half  inches  by 
one  inch  and  a  half,  and  presenting  a  circumference  of 
three  and  a  half  inches.t  Examples  of  the  evacuation  of 
stones  so  large  as  these  are  by  no  means  uncommon.  The 
calculi  that  have  been  found  impacted  in  the  bowels  have 
in  many  instances  attained  considerable  dimensions.  As 
examples  I  might  mention  the  following :  a  stone,  measur- 
ing four  and  a  half  inches  by  two  and  a.  quarter  inches 
lodged  in  the  upper  part  of  the  jejunum;!  one  with  a 
circumference  of  three  and  three-eighths  inches  impncted 
in  the  lower  jejunum  ;§  one  two  inches  in  length  and 
with  a  circumference  of  four  inches,  also  in  the  jejunum ;  || 
and  another  an  inch  in  length  and  with  a  like  circum- 
ference impacted  in  the  ileum.TI  Fig.  78"^^  shows  a  stone 
two  inches  in  length  by  one  inch  and  a  quarter  in  breadth 
blocking  up  the  ileum.  An  interesting  case  has  been  re- 
corded of  a  woman,  aged  sixty-three,  who,  after  jDresenting 
for  five  days  the  symptoms  of  complete  intestinal  obstruc- 
tion, passed  a  gall  stone  of  more  than  an  inch  in  diameter. 
She  had  an  irreducible  enterocele  through  which  the  calculus 
must  have  passed. 

Some  of  the  larger  gall  stones  appear  as  casts  of  the  gall 
bladder  which  they  probably  entirely  occupied  before  they 

*  Path,  and  Pract.  Kesearches  on  Diseases  of  the  Stomach,  etc.,  p.  127, 
3rd.  ed.     London,  1837. 

t  See  case  by  Marshall ;  Trans.  Glasgow  Path,  and  Clin.  Soc,  1893, 
p.  227. 

X  Mr.  E.  Pye  Smith  ;  Path.  Soc.  Trans.,  vol.  v.,  p.  163. 

§  Dr.  Baly ;  ibid.,  vol.  x.,  p.  184, 

II  Eevue  Med.  de  la  Suisse  Homande,  No.  2,  1882,  p.  82. 

^  Dr.  Murchison ,  Path.  Soc.  Trans.,  vol.  xx.,p.  219. 

**  Museum  Royal  Coll.  of  Surgeons,  No.  2436. 


OBSTHUCTIUX   DUE    TO    GALL    STOXES. 


193 


were  dischargecl.  It  must  be  remembered  that  a  gall  stone 
when  once  lodged  in  the  intestine  may  become  enlarged  by 
subsequent  deposit  upon  it  of  earthy  matters.  Leichtenstern 
describes  such  a  stone  that  had  a  circumference  of  about 
five   inches,  and  a  diameter  of  about  one  inch  and  a  hal£ 


Fig-.  78.— Gall  Stoue  impacted  in  the  Ileum. 

Tlie  stone  measured  2  inclies  by  IJ  inch,  and  lias  escaped  from  the  gall  bladder  by 
.  ulceration  into  the  duodenum.    {Royal  Coll.  of  Surg.  Mus..  Xo.  24-36.) 

1  removed  from  the  ileum  of  an  old  lady  a  calculus  with 
a  diameter  in  its  long  axis  of  one  inch  and  a  half.  Its 
nucleus  was  a  small  gall  stone,  and  its  large  size  was  due 
to  layers  of  mag-nesia  and  ftecal  matter.  The  patient  had 
taken  carbonate  of  magnesia  every  day  for  many  years 
isr 


194  OBSTRUGTIOX  DUE    TO    ENTEBOLITHS. 

The  concretion  is  in  the  museum  of  the  Royal  College  of 
Surgeons. 

On  the  contrary,  obstruction  of  the  bowels  has  been 
produced  by  gall  stones  of  comparatively  small  size.  Thus,  in 
the  museum  of  Guy's  Hospital  is  a  gall  stone  weighing  only 
55  grains  which  was  the  cause  of  fatal  intestinal  obstruc- 
tion. Israel  performed  laparotomy  in  a  case  of  intestinal 
obstruction,  and  found  a  gall  stone  in  the  lower  ileum 
with  a  diameter  of  only  2  cm.  It  was  assumed  that  the 
stone  had  caused  a  "  djmamic  obstruction "  by  spasm. 

The  point  in  the  intestinal  tube  at  which  the  stone 
lodges  is  most  frequently  in  the  lower  j^art  of  the  ileum  or 
in  the  duodenum  and  commencement  of  the  jejunum.  An 
examination  of  thirty-two  cases  by  Leichtenstern  gives  the 
following  result: 

In  the  duodenum  and  jejunum         .        .        .10  cases. 

In  the  middle  ileum 5      „ 

In  the  lower  part  of  ileum        .        .        .        .     17      „ 

32 

Courvoisier,  dealing  with  a  total  of  fifty-three  cases,  places 
the  site  of  the  obstruction  as  follows  : 

In  the  duodenum  and  jejunum         .        .  21"4  per  cent. 

In  the  ileum 65'4        „ 

At  the  ileo-cagcal  valve       ....  10  „ 

In  the  sigmoid  flexure        .        .        .         .  2  "4        „ 

It  is  obvious  that  if  the  calculus  has  passed  the  small 
intestine  and  the  valve  it  can  hardly  become  impacted  in 
the  colon,  although  there  may  be  some  difiiculty  in  the 
wa}^  of  its  evacuation  from  the  anus.  In  nearly  all  the 
fatal  cases  of  obstruction  by  a  calculus  the  impaction  has 
been  in  the  lesser  bowel. 

Korte,  however,  reports  a  case  of  acute  fatal  intestinal 
obstruction  due  to  the  impaction  of  a  gall  stone  in  the 
colon  of  a  woman,  aged  seventy-two.^ 

Although  intestinal  obstruction  when  due  to  gall  stone 
is  in  nearfy  every  instance  due  to  the  actual  plugging  of 
the  gut  by  the  stone,  yet  from  a  few  rej^orted  cases  it 
would  appear  that  the  calculus  in  its  passage  may  produce 
the  phenomena  of  volvulus  of  the  small  intestine.  Two 
examples  of  this  are  alluded  to  on  page  136. 

3.  Enteroliths. — Intestinal  calculi  or  enteroliths  may  be 
divided  into  three  classes. 

(I)  Concretions  formed  in  great  part  of  phosphate  of  lime, 

*  Berliner  klin.  Wochens.,  1893,  p.  690. 


OBSTRUCTION  DUE    TO    ENTEROLITHS.  105 

or  of  phosphate  of  magnesia,  or  of  the  triple  phosphate, 
or  stones  formed  of  mixtures  of  these  salts. 

Such  calculi  may  contain  also  some  carbonate  of  lime 
together  with  soda,  and  are  nearly  always  combined  with 
a  certain  amount  of  animal  matter  and  occasionally  with 
a  little  cholesterin.  In  appearance  they  are  heavy  and 
stone-like,  and  of  a  grey  or  pale-brown  colour  when  cleared 
of  fiEces.  On  section  they  show  a  concentric  arrangement 
of  chalk-like  or  dirty  white  layers.  With  such  layers 
often  alternate  others  of  a  brownish  colour.  In  outline 
they  are  rounded  or  oval,  and  often  appear  to  have  been 
polished  by  peristaltic  movements.  They  would  appear  to 
be  always  formed  around  a  nucleus  of  some  indigestible 
substance.  Among  such  may  be  mentioned  vegetable  fibres 
and  husks,  hair,  fruit-stones,  biliarj^  calculi,  pieces  of  bone, 
and  little  foreign  bodies  that  have  been  accidentally  swal- 
lowed. 

The  concretion  is  usually  single  and  of  quite  small  size. 
It  is  seldom  larger  than  a  chestnut,  although  a  few  isolated 
instances  of  large  stones  have  been  recorded. 

Dr.  Hector  Mackenzie^  reports  the  case  of  a  woman  of 
seventy  from  whose  rectum  a  concretion  was  removed 
weighing  497  grains.  It  was  irregularly  cuboidal,  and  was 
about  the  size  of  the  astragalus.  It  was  almost  entirely 
covered  by  large  crystalline  prisms.  It  proved  on  examina- 
tion to  be  composed  of  ammonio-magnesian  phosphate. 
The  nucleus  appears  to  have  been  formed  by  a  broken 
fragment  of  an  incisor  tooth  vfhich  she  had  swallowed  sixteen 
years  previously. 

In  Leichtenstern's  list  of  such  calculi  are  three  whose 
respective  circumferences  are  four  and  a  half,  seven  and 
a  half,  and  nine  inches.  Mr.  P.  H.  Watson  records  one 
one  inch  and  three-eighths  in  length  and  one  inch  and  one- 
eighth  in  width.  In  cases  where  several  stones  exist  they 
will  usually  be  found  to  be  faceted  by  mutual  contact  and 
pressure.  In  a  case  of  Monro's  twelve  calculi  were  evacu- 
ated, and  in  a.  case  of  Niemeyer's  no  less  than  thirty-two 
that  collectively  weighed  two  and  a  half  pounds. 

The  precise  circumstances  which  lead  to  the  formation 
of  these  calculi  are  not  yet  fully  understood.  They  are 
allied  to  the  concretions  found  so  often  in  the  vermiform 
appendix.  It  is  possible  that  in  certain  examples  the  salts 
which  form  the  concretion  are  derived  from  the  copious 
fluid  which  may  result  from  chronic  catarrh  of  the  bowel. 
There   is  little   doubt   but   that   such   catarrh  forms   a   very 

*  Path.  Soc.  Trans.,  Lond.,  1892,  p.  70. 


196  0B8TBUGTI0N   DUE    TO    ENTEROLITHS. 

important  factor  in  the  production  of  the  concretions  found 
in  the  appendix.  The  pathology  of  such  calculi  is  identical 
with  that  of  the  rhinolith,  which  is,  without  doubt,  a 
product  of  a  copious  and  long-continued  catarrh  of  the  nasal 
passages. 

Into  the  composition  of  such  concretions  as  those  now 
under  consideration  fsecal  matter  enters  largely.  The 
section  of  a  hardened  mass  of  long  retained  faeces  will  often 
bear  a  suggestive  resemblance  to  these  undoubted  enteroliths. 

It  is  not  always  easy  to  separate  these  concretions  from 
those  which  are  described  below  as  belonging  to  the  third  class. 

One  very  distinctly  stony  concretion  which  I  removed 
from  the  sigmoid  flexure  of  a  hypochondriacal  man  proved 
on  examination  to  be  composed  solely  of  ver}^  inspissated 
fsecal  matter.  It  was  easily  felt  through  the  parietes  before 
the  operation,  and  until  it  was  bisected  it  well  merited  the 
appellation  of  a  "stone." 

(2)  Enteroliths  of  low  specific  gravity  and  of  irregular  form 
which  are  porous  in  appearance  and  have  the  consistence  of 
compressed  sponge.  They  are  composed  mainly  of  densely 
felted  masses  of  vegetable  fragments  mixed  with  particles  of 
faecal  matter,  and  with  a  certain  amount  of  calcareous  material 
similar  to  that  met  with  in  the  above  species  of  stone.  These 
concretions  comprise  the  "  oat  stones  "  or  avenoliths,  Avhich 
are  composed  of  the  indigestible  fragments  of  oatmeal.  They 
are  said  to  be  not  infrequently  observed  in  Scotland  and 
amongst  people  where  much  coarse  oatmeal  is  eaten.  These 
stones  are  usually  small  and  single.  Leichtenstern  states  that 
there  are  seldom  more  than  two  together,*  and  adds  that  they 
vary  in  size  from  a  chestnut  to  an  orange. 

Khalofofff  reports  the  following  case  :  A  woman,  aged 
fifty,  had  suffered  for  many  years  from  periodic  attacks  of 
abdominal  pain  attended  by  distension,  vomiting,  and  con- 
stipation. Two  hard  globular  movable  tumours  were  dis- 
covered in  the  abdomen.  Laparotomy  was  performed,  and  the 
two  tumours — which  were  found  lodged  in  the  bowel — were 
removed.  They  proved  to  be  very  light  enteroliths,  measuring 
respectively  0  and  4|  cm.  in  diameter.  They  were  found  to 
consist  of  fine  ligneous  hairs  or  fibres  of  some  tree  with 
admixture  of  rye  and  oat  scales.  The  patient  had  been 
habitually  eating  bad  bread  made  with  flour  adulterated  with, 
some  ligneous  substance.     She  made  a  good  recovery. 

*  Dr.  Harley  reports  a  case  where  twenty  oat-stones  had  been  passed  at. 
different  times.  They  were  small,  were  the  colour-  of  brown  sandstone,  looked, 
on  section  like  felt,  and  floated  in  water.     Path.  Soc.  Trans.,  vol.  xi.,  p.  87. 

t  Annual  of  the  Universal  Med.  Sciences,  1891,  vol.  iii,,  C-40. 


OBSTRUCTION  DUE    TO    ENTEROLITHS.  197 

Closely  allied  with  such  enteroliths  are  certain  concretions 
of  indigestible  matters  which  belong  perhaps  more  properly  to 
the  list  of  "foreign  bodies."  (See  page  190.)  Thus  Dr.  Harley 
reports  a  case  in  a  man,  aged  hfty-six,  where  a  solid  mass, 
measuring  nine  inches  in  length  and  six  and  a  half  in 
circumference,  was  passed  after  five  weeks  of  suffering.  It 
was  composed  of  undigested  animal  matters  of  various  kinds 
densely  felted  together.  The  same  author  mentions  the  case 
of  a  woman,  aged  twenty-five,  who,  after  having  dysentery  for 
two  months,  passed  a  hard  mass  the  size  of  a  small  hen's  egg. 
The  mass  had  the  appearance  of  a  phosphatic  calculus,  but 
proved  upon  examination  to  be  composed  solely  of  starch."^ 
In  a  case  by  Dr  Down,  fatal  obstruction  was  caused  by  a 
stone-like  mass  the  size  of  a  hen's  egg  that  had  become 
impacted  in  the  lower  ileum.  It  was  composed  of  densely 
packed  cocoa-nut  fibres,  and  had  probably  been  formed  in  the 
stomach  and  then  passed  into  the  bowel.  The  patient  had 
been  eno-asred  in  mat-makinsr.t 

(3)  Concretions  formed  of  insoluble  mineral  matters  that 
liave  been  swallowed  as  medicines.  These  are  most  frequently 
composed  of  magnesia.  In  a  case  recorded  by  Mr.  Hutchin- 
son a  huge  mass  with  a  circumference  of  at  least  fifteen 
inches  was  felt  in  the  rectum.  It  had  a  surface  that  was 
hard  and  rough  like  an  oyster  shell.  It  was  broken  up 
and  removed  at  several  sittings.  It  was  found  to  be  com- 
posed of  magnesia  and  iron  with  some  earthy  matters  and 
many  thousands  of  strawberrj^  seeds.  The  patient  had  been 
in  the  habit  of  taking  large  doses  of  carbonate  of  magnesia 
and  of  iron,  i 

The  following  case  is  recorded  by  Schroeder.  §  A  man, 
aged  fifty-three,  had  suffered  for  many  years  from  severe 
attacks  of  colic,  attended  by  meteorism  and  obstinate  con- 
stipation. One  day  he  passed  a  hard  concretion,  and  gradu- 
all}'  lost  all  his  symptoms.  The  concretion  was  small,  and 
weighed  62  grains.  It  was  composed  of  carbonate  and  phos- 
phate of  lime  with  a  considerable  admixture  of  red  oxide  of 
iron.  The  patient  had  had  a  long  course  of  treatment  by 
Marienbad-Kreuzbrunnen  water,  which  contains  chalybeates 
in  the  form  of  carbonate  of  iron. 

In  a  case  reported  by  Men  tin  ||  a  patient  had  taken  much 

*  Path..  Soc.  Trans.,  vol.  xi. ,  p.  87. 

t  Ibid.,  vol.  xviii.,  p.  98.  For  other  cases  see  Brit.  Med.  Journ.,  March  29. 
lS8i,  p.  608. 

i  Path.  Soc.  Trans.,  vol.  vi.,  p.  203. 

§  Annual  of  the  Universal  Med.  Sciences.  1892,  vol.  i.,  D-21. 

il  Ibid. 


198 


OBSTRUCTION  DUE    TO    ENTEROLITHS. 


subnitrate  of  bismuth  for  persisting  intestinal  catarrh.  At 
the  post-mortem  a  bean-shaped  bod}^  was  found  in  the 
caecum  composed  of  85  per  cent,  of  subnitrate  of  bismuth 
and  of  15  per  cent,  of  organic  substances.     The  concretion 


had  given  no  trouble. 


Hadden^  reports  the  case  of  a  girl,  aged  seven  years, 
who  suffered  for  several  months  from  intestinal  catarrh, 
for  which  she  had  been  treated  with  chalk  and  with  bismuth. 


Fig.  79. — Obstruction  of  the  small  Intestine  by  a  Concretion  of  Magnesia. 
The  wall  of  the  bowel  has  been  cut  away  in  two  places  to  show  the  eoneretion. 

The  child  died,  and  at  the  post-mortem  nineteen  calculi 
varying  in  size  from  an  orange  pip  to  a  large  cherr}^  were 
found  in  the  transverse  colon.  They  were  composed  of 
tricalcium  phosphate,  calcium  carbonate,  organic  matter, 
and  moisture. 

Fig.  79  is  taken  from  a  specimen  in  St.  Thomas's  Hospital 
Museum, t  which  shows  the  small  intestine  at  one  point 
almost  entirely  blocked  by  a  dense  mass  of  magnesia  which 
fills  the  gut  for  several  inches.  Bamberger  noticed  a  stone 
containing  mainly  carbonate  of  lime  ih  a  patient  who  had 
taken  much  chalk  for  years.  In  a  patient  of  Mr.  Erichsen's 
a  small  stone  was  passed  after  much  intestinal  irritation.  It 
was  of  a  dark  brown  colour,  and  had  the  aspect  of  a  uric 


»  Trans.  Path.  Soc,  1888,  p.  131. 


t  No.  R  1. 


OBSTRUCTION   DUE    TO    ENTEROLITHS.  199 

acid  calculus.  It  was  found  to  be  composed  of  gum  benzoin. 
The  patient  was  a  singer,  and  had  been  in  the  habit  of 
taking  little  pills  of  gum  benzoin  to  improve  his  voice. 

Enteroliths  are  most  commonly  found  in  the  colon,  and 
with  especial  frequency  in  the  caecum.  In  the  colon  they 
often  occupy  the  sacculi  of  the  gut.  They  are  often  met 
with  also  in  the  rectal  ampulla,  and  more  rarely  in  the  ileum, 
and  in  true  and  false  diverticula. 

Taken  collectively  they  may  be  said  to  be  met  with  most 
often  in  young  adults  and  in  individuals  of  middle  age. 

Enteroliths  seldom  occasion  intestinal  obstruction.  Leich- 
tenstern  could  find  only  twenty  examples  among  1,152 
instances  of  obstruction  of  the  bowels.  Five  of  these  patients 
were  females,  and  the  remaining  fifteen  males. 

It  is  evident  that  these  stones,  especially  the  more 
calcareous,  are  of  very  slow  formation.  They  may,  moreover, 
be  dormant,  as  it  were,  for  years,  or  excite  during  that  time 
but  insigniticant  symptoms.  In  Mr.  Hutchinson's  case  of 
magnesian  enterolith  the  patient  was  an  elderly  woman.  She 
had  been  in  the  habit  of  takmg  magnesia  and  iron  thirty 
years  before  she  came  under  observation,  and  she  had  dis- 
continued the  use  of  those  drugs  for  no  less  than  twelve  years. 
For  the  eleven  years  that  preceded  the  evacuation  of  the 
concretion  she  had  simply  suffered  from  constipation. 

It  may  be  convenient  here  to  mention  the  subject  of  salol 
calculi.  Salol  is  extensively  used  by  many  in  cases  of 
intestinal  disorder,  and  its  disposition  to  form  calculous 
masses  is  now  fully  recognised.  Some  years  ago  in  a  case 
in  which  I  had  performed  left  colotomy  for  cancer  of  the 
rectum  the  nurse  discovered  in  the  ftecal  discharge  occasional 
hard  substances,  the  largest  of  which  was  the  size  of  the  tip 
of  the  little  finger.  These  masses  were  flat  and  showed  no 
evidence  of  being  rounded.  They  looked  crystalline,  were 
semi-opaque,  and  of  a  yellow  colour.  I  could  only  compare 
them  to  pieces  of  amber.  They  smelt  of  salol,  paid  I  submitted 
them  to  a  chemist,  who  said  they  were  composed  of  salol,  but 
in  a  form  unfamiliar  to  him.  The  patient  had  been  taking 
salol  for  some  weeks. 

A  little  later,  in  May,  1894, 1  had  performed  right  colotomy 
for  cancer  of  the  ascending  colon.  The  patient  had  taken 
much  salol,  and  the  same  amber-like  bodies  escaped  from  the 
artificial  opening  in  the  csecum.  Both  these  j)atients  had 
taken  salol  in  the  form  of  tabloids.  The  subject  of  salol 
calculi  has  been  fully  dealt  with  by  Dr.  Marshall  in  a  recent 
communication.^ 

*  £rit.  Med.  Journ.,  July  10,  1897. 


200  OBSTRUCTION    DUE    TO    ENTEROLITHS. 

He  gives  the  following  cases : — Dr.  Bradbury's  case :  A 
young  lady  had  taken  10  grains  of  salol  in  a  cachet  once 
or  twice  a  day  for  some  months.  At  the  end  of  six  months 
she  began  to  have  attacks  of  colic,  accompanied  by  vomiting 
and  needing  morphia.  In  one  of  these  attacks  she  vomited 
a  salol  calculus  weighing  1  gramme,  and  then  stated  that 
like  masses  had  been  frequently  passed  by  the  bowel.  M. 
Girode,  in  a  case  of  cholera  in  which  salol  had  been  given 
for  two  days  before  death,  found  in  the  stomach  at  the 
autops}^  two  masses  of  salol  weighing  3  grammes.  Dr. 
Brossard's  case  concerns  a  neurasthenic  lady,  aged  forty-five, 
suffering  from  gastric  dilatation,  with  paroxysmal  gastralgia 
and  hyperchlorhydria.  Vomiting  was  frequent,  and  was 
sometimes  accompanied  by  hsematemesis.  The  patient  re- 
fused lavage,  and  the  treatment  consisted  in  the  administra- 
tion of  large  doses  of  alkalies  and  a  milk  diet.  The  attempt 
at  a  milk  diet  produced  febrile  symptoms,  and  salol  and 
calomel  were  therefore  given.  The  salol  was  administered 
in  0-5-gramme  (7^  grain)  doses,  and  4  to  5  grammes  (62 
to  77  grains)  were  given  daily.  After  ten  days  (that  is,  after 
the  administration  of  40  grammes,  rather  more  than  1^ 
ounce),  the  patient,  who  was  habitually  constipated,  presented 
severe  sj-mptoms  of  intestinal  obstruction.  Purgatives,  large 
enemata,  the  continuous  current,  were  repeatedly  tried,  but 
without  effect,  and  the  symptoms  continued  for  thirty-six 
hours.  Finally,  a  motion  was  passed,  and  thinking  that  a 
biliar}^  calculus  might  have  produced  the  pain  it  was  care- 
full}^  washed.  About  ten  crystals,  weighing  altogether  4 
grammes  (62  grains)  were  found,  the  largest  of  which 
weighed  1'8  gramme.  Similar  small  calculi  occurred  in  the 
two  following  motions.     They  all  consisted  of  pure  salol. 

Before  concluding  the  present  chapter  it  may  be  well  to 
allude  to  the  subject  of  the  alleged  blocking  of  the  intestine 
by  means  of  intestinal  worms  or  by  intestinal  casts. 

M.  Martimon  describes  the  intestine  as  beiny'  sometimes 
blocked  by  a  mass  of  worms  which  forms  a  definite  tumour 
that  is  dull  on  percussion  and  can  be  felt  through  the 
abdominal  parietes.  The  nature  of  the  mass,  he  asserts,  can 
be  recognised  b}^  "  une  sorte  de  mi&uvement  vermiculaire 
sensible  a  la  main.""^  Many  less  recent  writers  describe  this 
variety  of  intestmal  obstruction,  and  lay  stress  upon  the 
characteristic  movementwhich  can  be  felt  in  the  occluding  mass. 

I  can  find  no  trustworthy  illustration  of  this  somewhat 
improbable   form   of  intestinal    obstruction.     Heller,   in   his 

*  Da  Traitement  de  rOcclusion  Intestinale  par  le  Mercure  metallique.    Paris, 
These,  No.  340,  1879. 


OBSTRUCTION  DUE    TO    WORMS,    ETC.  201 

able  monograph  upon  "  Intestinal  Parasites,"  thus  refers  to 
this  matter :  "  The  larger  species  (of  intestinal  worm)  have 
been  accused  of  giving  rise  to  intestinal  obstruction,  being 
able,  it  is  said,  when  entangled  into  a  ball,  to  close 
mechanically  the  Avhole  calibre  of  the  intestine.  Davaine 
very  properly  considers  this  an  erroneous  idea ;  for  cases 
have  been  known  where  the  intestine  Avas  literally  crammed 
with  hundreds  of  round  worms,  and  still  the  circulation  of 
the  chyme  through  the  interspaces  was  not  in  the  least 
interfered  with."'^ 

NotLnagel,  in  his  recent  work,  "Die  Erkrankungen  des 
Darmes,"  is  disposed  to  credit  the  reality  of  this  form  of 
obstruction,  and  alludes  to  the  observations  of  Hosier  and 
Peiper,  who  consider  that  ascarides,  if  present  in  sufficient 
numbers,  may  produce  intestinal  obstruction  and  volvulus. 

With  regard  to  intestinal  casts,  Dr.  Harleyt  reports  a 
case  in  a  woman,  aged  twenty-eight,  where  symptoms  of 
severe  obstruction  were  caused  by  fibrinous  concretions,  four 
in  number,  which  were  finally  discharged  from  the  anus  with 
immediate  relief  to  a  long  continued  train  of  distressing 
symptoms. 

One  of  these  masses  measured  three  and  a  half  inches 
by  two  inches.  They  were  described  as  densely  laminated 
and  fibrous-looking  on  section,  and  to  be  composed  apparently 
of  "  lymph." 

It  is  probable  that  these  masses  were  the  skin-like  casts 
of  membranous  colitis.  In  that  affection  "  skins  "  are  passed 
which  may  resemble  tape-worms,  or  an  entire  tubular  cast 
of  the  bowel  may  be  voided  which  may  measure  inches  or 
even  feet  in  length.  Usually  these  skins  or  casts  are  very 
thin,  but  some  have  been  as  much  as  one-fourth  of  an 
inch  in  thickness.  They  are  sufficiently  tenacious  to  be 
held  up,  are  structureless,  and  consist  of  albumen.  Some- 
times these  exfoliations  are  passed  rolled  up  into  solid  balls, 
with  or  without  fasces. 

It  may  be  questioned  if  these  skins  or  casts  ever  in  reality 
cause  intestinal  obstruction.  The  subjects  of  membranous 
colitis  are,  for  the  most  part,  chronic  dj'^speptics,  with  a 
marked  tendency  to  constipation.  They  are  liable  to 
"  attacks "  marked  by  severe  colic,  flatulence,  constipation, 
nausea  •  and  possibly  vomiting.  In  due  course  it  is  noticed 
that  "  skins "  are  being  passed,  and  relief  of  the  more  dis- 
tressing symptoms  is  experienced.  It  is  possible  that  the 
case  described  by  Dr.  Harley  comes  into  this  category. 

*  Ziemssen's  Cyclopaedia,  vol.  vii.,  p.  679. 
t  Path.  Soc.  Trans.,  vol.  xi.,  p.  87. 


202 


CHAPTER  VIII. 

STEICTUEE   OF  THE  INTESTINE. 

UxDER  the  general  term  "  stricture  of  the  intestme "  should 
possibly  be  included  all  those  morbid  conditions  of  the  bowel 
which  have  led  to  a  definite  narrowing  of  its  lumen. 

For  purposes  of  convenience,  however,  and  to  avoid 
bringing  together  under  one  hea,ding  many  perfectly  dis- 
tinct pathological  processes,  it  is  well  that  the  term 
"  stricture "  be  limited  to  a  narrowing  of  the  lumen  brought 
about  by  changes  in  the  coats  of  the  bowel  itself. 

Thus,  for  example,  one  would  exclude  from  the  present 
category  cases  of  stenosis  of  the  bowel  due  to  the  con- 
traction, of  inflammatory  products  in  the  peritoneum,  and 
those  instances  of  narrowing  of  the  bowel  from  kinking, 
from  the  rigid  bending  effected  by  adhesions,  from  the 
matting  together  of  sundr}^  coils,  and  from  the  shrinking 
of  the  mesenter}^     {See  pages  80  and  88.) 

All  strictures  of  the  intestine  may  be  divided  into  three 
classes : — 

1.  Cicatricial  or  simple   stricture,   due   to   cicatrisation  after  non- 

malignant  ulcer  of  the  bowel. 

2.  Cancerous  stricture,  due  to  deposits  of  carcinoma  in  the  bowel 

wall. 

3.  Congenital  stricture,  due  to  defects  in  development,  and  possibly 

to  other  intra-uterine  changes. 

After  the  consideration  of  these  three  forms  of  stricture, 
it  will  be  desirable  to  deal  with  the  someAvhat  anomalous 
conditions  described  under  the  title  of  "  Idiopathic  dilatation 
of  the  colon." 

I.  The  Cicatricial  Stricture. — This  depends  upon  the 
contracting  of  a  cicatrix  consequent  upon  loss  of  substance 
by  ulceration  or  limited  gangrene  of  the  inner  coats.  The 
aspect  and  degree  of  the  stricture  Avill  obviously  depend  upon 
the  situation  and  extent  of  the  original  loss  of  substance.     A 


GICATlUaiAL    S  TRIG  TUBE.  203 

limited  patch  of  ulceration  placed  in  the  long  axis  of  the 
bowel  may  lead  to  very  insignificant  narrowing  of  its 
lumen,  while  an  ulcer  no  more  extensive  but  disposed  trans- 
versely around  the  gut  may  produce  an  annular  constriction 
which  may  almost  close  the  tube.  Some  contracting  cicatrices 
may  merely  alter  the  course  or  direction  of  the  bowel ;  others 
that  are  not  annular  may  pucker  up  a  portion  of  the  intes- 
tinal wall  and  produce  great  distortion  of  the  tube,  but 
without  much  narrowing  of  it.  An  evenly  distributed  scar 
may  produce  a  regular  narrowing  of  the  bowel,  while  an 
unequally  contracting  cicatrix  may  produce  obstruction  as 
Avell  by  actually  diminishing  the  size  of  the  canal  as  by 
distorting  the  intestinal  walls. 

It  will  be  readily  understood  that  the  cicatrix  which 
produces  the  greatest  amount  of  harm  with  the  least  amount 
of  contraction  is  that  which  assumes  an  annular  form  ;  while 
the  least  harmful  cicatrix  is  the  one  which  is  longitudinal 
in  direction  and  which  involves  only  a  part  of  the  circum- 
ference of  the  bowel. 

It  is  convenient  to  divide  the  cicatricial  strictures  into 
three  classes.  (A)  Those  depending  upon  primary  ulceration, 
(B)  Those  which  are  subsequent  to  lesions  following  strangu- 
lated hernia.  (C)  Those  which  may  follow  injury.  The  first 
class  concerns  both  the  large  and  small  intestine.  The 
others,  so  far  as  the  cases  I  have  collected  serve  to  show, 
concern  only  the  lesser  bowel. 

(A)  Stricture  after  Ulceration. — There  is  no  doubt  but 
that  our  knowledge  of  the  ulcerative  processes  in  the 
intestine  is  still  very  far  from  complete.  The  actual  morbid 
appearances  have  been  somewhat  fully  described,  but  the 
interpretation  of  what  is  found  is  not  yet  quite  emphatic, 
and  the  clinical  phases  of  ulceration  in  the  bowel  are  still 
indistinctly  defined.  So  far  as  the  present  subject  is  con- 
cerned, it  is  manifest  that  stricture  is  a  comparatively  rare — 
probably  a  very  rare — result  of  ulceration  of  the  bowel. 
Non- malignant  ulcers  of  various  kinds  are  quite  commonly 
met  with  in  the  intestinal  canal.  In  the  great  majority  of 
instances,  such  ulcers  heal  and  leave  a  cicatrix.  Yet  stricture 
of  the  bowel  resulting  from  that  cicatrix  may  be  said  to  be 
quite  rare.  Narrowing  of  the  bowel  of  a  trifling  degree  will 
excite  no  clinical  manifestations,  and  in  speaking  of  stricture 
it  is  assumed  that  the  narrowing  produced  in  the  bowel  is 
such  as  to  cause  actual  obstruction. 

The  narrowing  of  the  lumen  produced  by  a  stricture 
may  be  intensified  by  peritoneal  adhesions,  by  some  bending 
of  the  stenosed  gut,  or  by  some  infolding  of  the  intestinal  wall. 


204  STRICTUEE    OF    THE    INTESTINE 

From  tlie  account  of  a  case  wliicli  I  have  alluded  to 
in  a  subsequent  section,  dealing  with  the  tuberculous  ulcer 
(page  207),  it  would  appear  that  chronic  inflammatorj^  thicken- 
ing of  the  bowel  wall  may  produce  such  narrowing  of  the  gut 
as  to  cause  obstruction. 

The  following  forms  of  intestinal  ulcer  may  be  considered. 

1.  DuoDEXAL  Ulcer.^ — Ulcers  of  different  kmds  are  de- 
scribed as  occurring  in  the  duodenum.  They  have  been 
found  associated,  according  to  various  writers,  with  Bright's 
disease,  heart  disease,  septicemia,  and  enteric  fever.  Tuber- 
culous ulcers  are  very  rare  in  the  duodenum,  although 
they  are  not  enthely  unknown  in  that  part. 

The  duodenal  ulcer  associated  with  burns,  and  especially 
with  extensive  burns  of  the  trunk,  is  met  with  chief!}'  in 
young  subjects,  and  usually  during  the  inflammator}'  stage 
of  the  burn.  It  is  probable  that  a  septic  embolus  leads  to 
a  hsemorrhagic  infiltration,  and  that  by  the  action  of  the 
gastric  juice  this  is  changed  into  an  ulcer.  There  is  no 
evidence  that  this  ulcer  has  ever  led  to  a  stricture. 

The  simple  ulcer  of  the  duodenum  has  the  same  patho- 
geny as  the  simple  ulcer  of  the  stomach.  It  is  more 
common  in  males  than  in  females,  and  the  average  age  is 
stated  to  be  between  thirty  and  forty.  The  ulcer  is  nearly 
always  found  in  the  first  part  of  the  duodenum,  and  on 
the  anterior  wall.  It  is  very  rare  m  the  second  part,  and 
still  rarer  in  the  third.  As  a  rule,  the  ulcer  is  single, 
and  resembles  the  gastric  ulcer  in  form   and  dimensions. 

This  ulcer  may  lead  to  severe  and  even  fatal  bleeding, 
to  perforation,  to  subphrenic  abscess,  and  to  stricture  of 
the  duodenum.  It  may  compress  b}^  its  cicatrix  the  bihary 
papiUa,  and  cause  persisting  jaundice.  It  may  deepen  and 
burrow  into  the  gall  bladder,  the  bowel,  or  even  the  aorta. 

Owing  to  the  large  size  of  the  duodenum  and  the  fluid 
character  of  its  contents,  a  stricture  suflicientl}'  narrow  to 
cause  symjDtoms  of  obstruction  is  certainly  uncommon. 

Dr.  F.  Lange"^  reports  a  very  good  example  of  stenosis 
of  the  duodenum  due  to  the  cicatrisation^  of  an  ulcer  near 
the  pylorus.  The  patient  presented  first  the  symptoms  ol 
ulcer  of  the  stomach,  and  later  those  of  stricture  of  the 
pylorus.     She  was  cured  by  operation. 

Another  good  example  of  this  stricture  is  reported  b}'  Boas.f 

In  certain  examples  of  non-malignant  stricture  of  the 
duodenum  it  would  appear  that  gall  stones  have  caused  the 
ulceration  which  led  to  the  cicatrix. 

*  Annals  of  Sureerv,  vol.  i.,  1S93,  p.  588. 

t  Annual  of  theljmversal  3,Ied.  Sci.,  1892,  vol.  i.,  D-11 


TUBERCULOUS    ULCER.  205 

Hochhaiis"'^  reports  three  cases  of  this  association.  In 
one  the  stenosis  was  close  to  the  pylorus,  in  another  close 
to  the  jejunum,  while  in  the  third  case  both  duodenuni 
and  pylorus  were  involved. 

2.  Tuberculous  Ulcer. — This  ulcer  is  of  common  occur- 
rence. It  is,  however,  desirable  to  remember  that  every 
ulcer  met  with  in    the   bowel  of  those   who   have   died   of 


Fig.  80. — Tuberculous  Ulcer  of  a  Peyer's  Patch  in  process  of  Healing. 
{Royal  Coll.  of  Surg.  Mus.,  No.  2544  A.) 

tuberculosis  is  not,  of  necessity,  tuberculous.  Tuberculous 
ulcers  are  met  with  in  all  parts  of  the  intestine,  but  are  most 
common  in  the  lower  extremity  of  the  ileum.  They  be- 
come more  and  more  rare  as  the  stomach  is  approached. 
They  often  involve  a  great  extent  of  the  bowel,  and  are  apt 
to  be  multiple.  They  take  origin  in  Peyer's  patches  and 
in  the  solitary  glands.  Fig.  80  shows  a  tuberculous 
ulcer  in  a  Peyer's  patch.  Its  base  was  studded  with 
miliary  tubercles.  The  patient  had  phthisis.  Caseation  is. 
produced,  and  the  breaking  down  of  the  unstable  cheesy 
mass  leads  to  the  ulcer.  The  ulcers  tend  to  extend  trans- 
versely, and  may  in  certain  instances  entirely  encircle  the^ 
bowel. 

*  Berliner  klin.  Wocliensclirift,  1891,  No.  17,  p.  409. 


206 


STBIOTUEE    OF    THE    INTESTINE. 


become  large  and  irregular, 
has  thick  overhansi'inaf  edges 


Sometimes  the  extension  is  in  the  long  axis  of  the 
intestine.  In  character  the  ulcer  closely  resembles  such  a 
tuberculous  ulcer  as  may  now  and  then  be  seen  in  the  pharynx. 
The  ulcers  are  at  first  small  and  round,  and  later   tend   to 

The  typical  ulcer  is  excavated, 
and  an  uneven  floor. 
There  may  be  considerable  undermining  of  the  mucous 
membrane."^  Perforation  is  rare.  Eisenhardtt  found  perfora- 
tion in  twenty-eight  out 
of  566  cases  of  intestinal 
tuberculosis,  examined 
post-mortem.  Some 
stenosis  as  a  result  of 
cicatrisation  of  the  ulcer 
is  not  uncommon,  but  it  is 
certain  that  it  very  often 
fails  to  reach  a  stage 
sufficient  to  produce  any 
symptoms.  There  are, 
however,  man}^  examples 
of  quite  dense  and  rigid 
tuberculous  strictures. 

The  ulcer  may  heal 
in  one  part  and  progress 
in  another. 

The  ulcer  may  lead 
to  peritoneal  adhesions 
and  even  to  an  intestinal 
fistula.  A  healed  ulcer  is 
shown  in  Fig.  81. 

The     strictures     pro- 
duced by  the  tuberculous 
ulcers  are  often  multiple.     Fig.  82  shows  two  annular  stric- 
tures close  together.     Voehts  J  records  a  case   in  which  the 
two  strictures  were  six  feet  apart. 

In  a  case  by  Dr.  Handford,§  in  addition  to  a  dense 
tuberculous  stricture  of  the  rectum  two  inches  long,  there 
were  two  strictures  in  the  small  intestine. 

Dr.  RoUeston  ||  describes  a  case  with  three  strictures 
of  moderate  degree  all  situated  in  the  colon. 


Fig.  81. — Healed  Tuberculous  Ulcer  of  the  Ileum. 
(Royal  Coll.  of  Surg.  Mus.,  No.  2544  B.) 


1891. 


*  Path.  Soc.  Trans.,  1898,  p.  102. 

t  Ibid.,  1888,  p.  116. 

J  Ueber  die  Haufigkert  und  vorkommen  der  Darmtubcrculose. 

Annals  of  Surgery,  1893,  p.  579. 
Path.  Soc.  Trans.,  1858,  p.  117. 


Munich, 


TUBERCULOUS    ULCER. 


207 


In  a  case  recorded  by  Dr.  C.  White  "^  there  were  four 
dense  strictures  in  the  jejunum,  and  one  in  the  ascending 
colon ;  the  ctecum  would  only 
admit  the  little  finger.  The 
patient  Avas  a  man  of  fifty-two. 

In  some  of  the  recorded  cases 
as  many  as  five  and  seven  stric- 
tures— all,  as  a  rule,  of  quite 
moderate  degree  —  have  been 
found  in  the  bowel  at  the  same 


time. 

Fio's.  83  and  84  are  from  the 
case  of  an  adult  affected  with 
phthisis,  in  whose  ileum  three 
tuberculous  strictures  were  found. 
Fig.  83  shows  an  abrupt  stricture 
of  severe  deo-ree.  Fisf.  84  £'hows 
a  stricture  associated  with  much 
thickening  and  some  persisting 
ulceration.  I  have  recorded  a 
case  in  a  boy,  aged  fifteen,  in 
which  there  was  a  hard  and  rigid 
stricture  in  the  ascending  colon 
which  only  admitted  the  tip  of 
the  little  finger.t 

Peasej  operated  upon  a  stric- 
ture of  the  ileo-C£ecal  valve,  due 
to  a  tuberculous  ulcer.  Fig.  81 
shows  a  healed  tuberculous  ulcer 
which  had  caused  no  stenosis. 
There  is  simply  a  pigmented 
radiating  scar.  The  specimen  was 
obtained  from  the  body  of  a  man, 
aged  thirty-seven,  who  died  of 
phthisis  and  whose  small  intestine 
showed  many  healed  tuberculous 
ulcers. 


The  folloAving  remarkable  case  yig.  82.— Portion  of  Jejumim  sho-?^ 


The  gut  lias  been  turned  inside  out  so  as 
to  sliONV  the  mucous  surface. 


by  Nothnagel§  may  be  mentioned 
in  this  place.  The  patient  was  a 
man  of  forty  years,  who,  eighteen 
months  before  his  death,  was 
troubled  by  constipation   and  severe   colic 

*  Path.  Soc.  Trans.,  1890,  p.  131. 

t  Ibid.,  1888,  p.  113. 

+  BuU.  de  I'Acad.  de  Med.,  Dec.  30,  1890. 

§  Die  Erkrankungen  des  Darmes,  Vienna,  1896 


ing  two  Strictures,  the  result  of 
Tuberculous  Ulceration. 


The   symptoms 


208 


STRICTURE    OF    THE    INTESTINE. 


became  more  and  more  marked,  and  two  months  before  death 
a  hard  round  tiimom%  the  size  of  a  walnut,  was  discovered 
in  the  ileo-csecal  region.  It  was  behoved  to  be  cancerous. 
Laparotomy  was  performed,  and  the  involved  intestine 
(which    represented    the    ileo-csecal  junction)    was    excised. 

The  tumour  Avas  the  size  of  a 
hen's  egg  and  very  hard.  It 
had  narrowed  the  lumen  of  the 
bowel  to  the  size  of  a  pencil. 
There  was  no  ulceration.  The 
microscope  revealed  no  trace  of 
a  new  growth,  but  showed  that 
the  mass  was  the  result  of 
chronic  inflammation,  and  that 
scattered  among  it  were  a  few 
tubercle  bacilli.  The  patient 
survived  the  operation  three 
weeks. 

Konig^  reports  five  cases  of 
tuberculous  stricture  treated  by 
operation. 

3.  Syphilitic  Ulcer. — Ex- 
cluding the  rectum  syphilitic 
ulcers  of  the  bowel  are  rare. 
They  may  be  met  with  in  any 
part  of  the  intestine,  but,  ac- 
cording  to   Rieder,t   are  most 

lumen  of  the  gut  is  only  a  OLuarter  of  an  inch.     commOU    in    the    UppOr    part    of 
^RoyalColl.ofSurg.Mus.,l^o.2mB.)  ^^^    ^^^^^^    ^^^^^j^ 

They  are  met  with  in  both 
inherited  and  acquired  syphilis,  and  depend  upon  the 
brealdng  down  of  gummatous  deposits.  In  the  small 
intestine  they  are  said  to  be  often  located  in  Peyer's  patches. 
The  ulcers  are  often  multiple,  are  rounded  at  first,  and  then 
tend  to  follow  the  transverse  axis  of  the  bowel.  Fig.  85 
shows  a  specimen  of  multiple  ulcers  of  the  colon  assumed 
to  be  syphilitic. 

It  is  said  that  syphilitic  ulcers  produce  stenosis  of  the 
bowel.  If  any  deductions  can  be  drawn  from  the  effects 
of  tertiary  syphilitic  ulceration  of  the  rectum  this  can  be 
quite  well  understood.     There  is  no  doubt  that  a  gumma  in 


Fig.  83. — Tuberculous  Strictui-e  of  the 

Ileum. 
At  the  site  of  the  stricture  the  diameter  of  the 


*  Deutsche  Zeitsch.  f.  Chir.,  1892,  p.  62.  See  also  cases  hy  Sachs  (Archiv 
f.  klin.  Chir.,  1892,  B.  43).  Zahlmann  (Hosp.  Tidende,  1892,  No.  36).  Rentier 
(Bull,  et  Mem.  de  la  Soc.  de  Chir.,  1896,  No.  7)  and  the  author  (lancet,  Jan.  4, 
1896). 

t  Annual  of  the  Universal  Med.  Sciences,  1893,  vol.  i.,  D-31. 


TYPHOID    ULOEB. 


209 


the  wall  of  the  gut  may  lead  to  a  stricture  without  causing 
any  ulceration  ot  the  mucous  membrane. 

Fig.  86  shows  a  case  ot"  stricture  of  the  ileo-ca3cal  valve 
assumed  to  be  due  to  syphilis. 

4.  Typhoid  Ulcer. — The  characters  of  these  ulcers  are 
well  known.  They  lead  to  distinct  and  recognisable  scars, 
but  it  is  only  in 
extremely  rare  cases 
that  they  produce  any 
stenosis  ot  the  intes- 
tine. This  is  not  always 
easy  to  understand.  It 
is  true  that  the  primary 
typhoid  ulcer  is  often 
of  no  great  extent,  is 
arranged  parallel  to  the 
lonof  axis  of  the  bowel, 

•  -I 

and  involves  but  a  por- 
tion of  its  circumfer- 
ence ;  but  the  serpi- 
ginous ulcers  that  may 
follow  upon  the  primary 
lesion  are  often  very 
extensive,  involving 
large  tracts  of  the  in- 
testine, and  extending 
so  deeply  as  to  produce, 
in  a  few  instances,  per- 
foration. In  criticising 
a  case  of  reputed  stric- 
ture after  typhoid  it  is 
Avell  to  remember  that  the  morbid  process  is  usually  limited 
to  the  ileum.  It  extends  to  the  colon  in  about  50  per 
cent,  of  the  cases,  but  even  then  very  rarely  indeed  does  it 
go  beyond  the  caecum  or  ascending  colon.  In  the  other 
direction  also  it  is  extremely  unusual  for  the  disease  to 
extend  higher  than  three  metres  from  the  ileo-caecal  valve."* 
Klob  gives  a  case  of  stenosis  after  extensive  typhoid  ulcers. 
I  have  not  been  able  to  find  any  recorded  instance,  except 
this,  that  appears  to  be  an  undoubted  example  of  stricture 
after  enteric  iever.  Many  of  the  reputed  cases  do  not  bear 
examination,  and  the  association  of  a  previous  typhoid  with 
these  examples  is  probably  accidental. t 

*  See  Hoffman's  Statistics  ;   Untersiich.    iiber  die  path-anat.    Verilnd.  der 
Organe  heim  Abdominal  Typhus.     Leipzig:,  ]  869. 

t  See  for  examples,  case  by   Ur.    Bristowe  ;    Path.    Soc.   Trans.,    vol,    iv., 
O 


Fig.  84. — Tuberculous  Stricture  of  the  Ileum. 

{Koyal  Coll.  oj  Surg.  Mus.,  No.  2521  C.) 


210 


STRICTUBE    OF    THE    INTESTINE. 


5.  Dysenteric  Ulcer. — The  ulcers  left  by  dysentery  are 
occasional  causes  of  stricture.  These  ulcers  may  be  met 
with  in  the  rectum  alone  or  in  the  sigmoid  flexure  or  in 
the  caecum  alone.  In  general  terms  it  may  be  said  that 
they  become  less  common  as  one  passes  up  the  colon  from 
the  rectum.  In  some  instances  the  whole  of  the  large 
intestine    has   been   involved.      The  d3^senteric   ulcer   shows 


Fig.  85.— Syphilitic  "Ulcers  of  the  Colon. 

The  long  axes  of  the  ulcers  ai-e  transverse  to  the  axis  of  the  bowel. 
[Royal  Coll,  of  Surg.  Miis.,  No.  2491  A.) 


infinite  variations.  It  may  be  small  and  shallow,  or  large, 
irregular  and  deep.  It  may  assume  almost  any  outline. 
Fig.  87  shows  dysenteric  ulcers  of  the  lower  part  of  the 
colon,  some  of  which  are  healing.  The  ulcers  in  this  malady 
are  often  very  destructive.  They  have  a  tendency,  as  they 
spread  and  fuse,  to  isolate  little  patches  of  mucous  membrane, 
which  remain  undestroyed  and  stand  out  like  islands  among 
the  ulcerated  districts.  As  the  scar  contracts  these  islands 
are   often   rendered   very   prominent,   and   project   from  the 

p.  152.       Case   by  Dr.   Lnrguier  des  Banctls  :  These  de  Paris,  No.    142.   1870 
D.  86, 


SYrHILITIC    ULCliR. 


'21] 


,"^v 


Ym.  86.— Syphilitic  Stricture  of  t)ie  lleo-caical  Yalv.j. 
{Royal  Coll.  of  Sufj.  Has.,  Xij.  l'622  A.) 


Fro.  S". — Dyseuteric  Ulcers  ot  the  Lower  Part  of  the  Colon. 
{Boyal  Coll.  of  Sarj    Miu.,  So.  24S2.) 


212 


STRICTURE    OF    THE    INTESTINE. 


surface  as  hard  warty-looking  excrescences.  The  cicatrix 
is  often  extensive,  rigid,  and'  dense.  The  contraction  may 
be    very    irregular.     The   gut    may   be    much   puckered,    or 

thrown  into  irregular 
folds  or  in  other  ways 
distorted.  The  mucous 
membrane  often  becomes 
undermined  during  the 
ulcerative  process,  and 
the  bands  of  membrane 
thus  isolated  commonly 
remain  as  rigid  bars  and 
cords  which  contribute 
one  more  element  to  the 
irregular  aspect  ot  the 
cicatrix.  Unilateral  scars 
may  produce  a  bending 
of  the  gut  or  may  cause 
sickle-like  folds  of  the 
intestinal  wall  to  project 
mto  the  lumen  of  the 
tube.  Such  folds  may 
act  the  part  of  valves  and 
increase  the  obstruction, 
and  the  same  may  some- 
times be  said  ot  the  eleva- 
tions and  excrescences 
which  so  often  mark  the 
dysenteric  cicatrix.  An 
example  of  stenosis  after 
dysentery  is  shown  in 
Fig.  88.^  I  think  that 
the  nature  of  the  more 
exuberant  of  the  cica- 
trices has  sometimes  been 
unrecognised.  I  believe 
that  not  a  few  instances 
of  so-called  "  scirrhus  "  of 
T?T^  OQ     c+  ^'^f^^  .  „  ,       f^    T,      J.   ■     the    colon   are    examples 

I'lG   88 — Stiictuie  of   Colon   after  Dysenteric  ^^  ,•       i  i  '-     -, 

Ulceration.  really     or     dense,     hard, 

dysenteric  scars,  associated 
with  much  contraction  and  with  firm,  warty  excrescences.  It 
is  not  improbable  that  one  of  the  specimens  of  "  scirrhus " 
shown  in  the  St.  Thomas's  Hospital  collectiont  is  really  an 

*  St.  Bart.'s  Hosp.  Museum,  No.  1987.     See  also  No.  1986. 
t  St.  Thomas's  Hosp.  Museum,  No.  Q  141. 


DYSENTERIC    ULCEIi.  213 

example    of"    extensive    contraction    after    dysentery,   and    I 
have  found  several  museum  specimens  which  are,   I   think, 


Fig.  89. — Extensive  Follicular  Ulceration  of   the  Sigmoid  Flexure   above  a 
Carcinoma  of  the  Eectum. 

(Royal  Coll.  of  Surg.  Mus.,  No.  2466  B.) 

susceptible  of  the  same  interpretation.     Dysenteric  strictures 
are   often   met   with    in    the    rectum,    sigmoid    flexure,   and 


214  STEW  TUBE    OF    THE    INTESTINE. 

descending   colon.      They   occur,   also,    at   both    the   hepatic 
and  the  splenic  flexures. 

6.  Follicular  Ulcer. — These  ulcers  are  much  more 
common  in  the  large  intestine  than  in  the  small.  They 
commence  in  the  solitary  follicles,  and  produce  small  round 
ulcers  with  sharply  cut  edges.  The  ulcers  are  multiple, 
and  are  often  so  extensive  that  the  gut  is  honeycombed 
by  them.  They  vary  in  size  from  a  hempseed  to  a  pea, 
and  may  produce  extensive  ulcerated  surfaces  by  fusion. 
This  condition  is  usually  met  with  in  association  with  other 
intestinal  disease,  such  as  dysenterj-,  typhoid  fever,  or 
colitis.  Fig.  89  is  from  a  case  in  which  the  sigmoid 
flexure  above  a  cancer  of  the  rectum  showed  extensive 
follicular  ulceration.  It  is  questionable  if  this  variety  of 
ulceration  leads  to  notable  stenosis.  When  in  the  lesser 
bowel  the  ulcers  are  usually  in  the  lower  ileum. 

7.  Catarrhal  and  other  Ulcers. — In  the  condition 
known  as  "  ulcerative  colitis "  there  may  be  very  extensive 
destruction  of  the  mucous  membrane.  Ulcers  are  formed, 
which  are  at  first  small  and  round  and  then  become  large 
and  irregular,  with  their  long  axes  at  right  angles  to  the 
long  axis  of  the  bowel.  The  prognosis  in  ulcerative  colitis 
is  grave,  and  there  is  little  direct  evidence  to  show  that 
the  condition    leads  to  an  actual  stricture. 

As  an  instance  of  multiple  stricture  of  the  lesser  bowel 
following  extensive  ulceration  of  an  unknown  character,  may 
be  quoted  a  well-described  case  by  Dr.  Sharkey  in  the 
Pathological  Society's  Transactions  for  1884. 

In  the  excellent  article  on  Diseases  of  the  Colon  in  Dr. 
Clifford  Allbutt's  "  System  of  Medicine,"  there  are  accounts 
of  the  "  vascular  ulcer,"  the  "  hsemorrhagic  ulcer,"  and  the 
"  trophic  ulcer."  So  far  as  I  am  aware,  the  ulcers  described 
under  this  name  have  no  known  connection  with  the  present 
subject. 

Returning  to  the  intestine  and  examining  the  simple 
strictures  of  that  tube,  which  may  be  ascribed  to  cicatrisation 
alter  ulcer,  one  is  impressed  with  the  comparative  valueless- 
ness  of  any  classification  of  ulcers.  In  some  instances,  there  is 
no  doubt  that  the  stricture  has  followed  a  dysenteric  or  tuber- 
culous ulcer,  or  there  are  reasons  for  supposing  that  it  is  due 
to  a  syphilitic  ulcer  ;  but  certainly,  in  the  majority  of  cases, 
the  conclusion  as  to  the  origin  of  the  stricture  is  purely 
negative.  Fig.  90  shows  a  very  pronounced  stricture  of  the 
ileo-ceecal  valve,  but  the  nature  of  the  stricture  and  the 
character  of  the  ulficration  which  led  to  it  are  matters  of 
pure  speculation. 


CICA  TRIG  Li  L    S  TliW  TUli  E. 


215 


Regarding  these  strictures  collectively,  it  may  be  said  that 
they  are  usually  definite  and  well  limited.  As  viewed  from 
the  peritoneal  surtace,  they  may  appear  merely  as  a  well- 
marked  constriction  of  the  gut,  as  it  a  cord  or  tape  had  been 
tied  about  it,  or  may  have  induced  more  distortion  of  the 
bowel.  The  former  condition  is,  perhaps,  more  often  met 
in  the  large  intestine,  and  the  latter  in  the  small.  In  the 
lesser  bowel,  the  strictured  part  is  usually  free  and  exempt  from 
adhesions  to  adjacent  surfaces.  In  the  colon,  however,  the 
stenosed  segment  is  often  bound  down,  especially  when  the 


Fig.  90.— Stricture  of  the  Ileo-ciBca.l  Valve.   A  quill  is  passed  through  the  Sfricture. 
Outside  the  Bowel  is  an  enlarged  Ljrmphatic  Gland. 

{Royal  Coll.  ofSurq.  Mus.,  No.  2551.) 


part  involved  is  one  or  other  of  the  flexures.  The  lumen  of 
the  narrowed  tube  may  be  regular  in  outline  or  much 
distorted. 

It  may  at  the  time  of  its  causing  death  admit  the  fore- 
finger, or  be,  on  the  other  hand,  so  small  as  hardly  to  permit 
the  introduction  of  a  probe. 

As  regards  locality,  strictures  of  the  lesser  bowel  are 
usually  situated  in  the  ileum,  and  preferably  in  the  middle  or 
lower  parts  of  the  ileum.  In  the  colon,  about  50  per  cent,  or 
these  cicatricial  strictures  are  in  the  sigmoid  flexure.     Next 


216  STRICTURE    OF    THE   INTESTINE 

in  frequency  come  the  descending  colon  and  splenic  flexure, 
and  beyond  those  parts  the  stenoses  become  rarer  and  rarer  as 
the  Ccecum  is  approached. 

In  comj)armg  the  large  intestine  with  the  small,  one  is 
struck  Avith  the  fact  that  the  simple  stricture  of  the  colon  is 
nearly  always  single.  Indeed,  out  of  the  recorded  cases  that  I 
have  collected  there  are  very  few  examples  of  multiple  simple 
stricture  of  the  large  intestine. 

In  the  specimen  from  which  Fig.  91  was  taken  there  was, 
in  addition  to  the  stricture  of  the  ileo-csecal  valve,  a  stricture 
of  the  ascending  colon.  In  another  instance,  the  patient,  a 
woman  aged  tAventy-nme,  had.,  in  addition  to  a  stricture  of  the 
rectum,  a  stricture  at  the  hepatic  and  at  the  splenic  flexures."^ 
On  the  other  hand,  out  of  eleven  recorded  cases  of  cicatricial 
stricture  of  the  lesser  bowel  there  were  six  instances  of  single 
stricture  and  live  of  multiple.  In  one  of  the  six  cases  there 
were  cicatrices  in  the  gullet  and  stomach  in  addition  to  that 
producing  stenosis  of  the  intestine,  t  The  five  cases  of 
multiple  stricture  present  certain  striking  characters  which 
are  common  to  the  series.  The  patients  were  all  women 
except  one.  They  were  all  young  adults,  their  ages  ranging 
from  twenty-two  to  thirty-three.  There  were  three,  four,  or 
more  definite  strictures  in  each  case,  Avhich  were  placed  at 
varying  distances  apart.  The  ileum  was  involved  in  each 
instance.  In  none  of  the  cases  was  the  nature  of  the  ulcera- 
tion upon  which  the  cicatrisation  depended  diagnosed.  J 

There  is  no  doubt  but  that  the  present  variety  of  cicatricial 
stricture  is  very  much  more  common  in  the  large  than  in  the 
small  intestine.  The  statistics,  however,  at  present  available 
are  not  sufficiently  extensive  to  form  the  basis  for  a  correct 
estimation  of  the  comparative  frequency. 

If  one  could  judge  roughly  from  a  general  examination  ot 
museum  specimens,  it  may  be  said  that  the  proportion  in 
which  the  large  and  small  gut  is  involved  appears  to  be 
about  as  6  to  1. 

I  have  met  with  many  recorded  instances  of  stenosis  of  the 
ileo-cpecal  valve  subsequent  to  the  cicatrisation  of  ulcers.  In 
some  of  the  cases  the  ulcers  appear  to  have  spread  from  the 
ileum,  and  in  other  examples  from  the  colon.  In  the  remain- 
ing cases  the  valve  alone  seems  to  be  involved.     The  degree 

*  M.  Marignac;  Bull,  de  la  Soc.  Anat.,  1877,  p.  519. 

t  Dr.  Bristowe ;  Path.  Soc.  Trans.,  vol.  xx.  p.  180.  The  nature  of  the 
cicatrice-j  was  unknown. 

J  As  a  good  example  of  the  series,  see  Kceherle's  famous  case,  in  which  he 
resected  with  success  two  metres  of  ileum  ;  Bull,  et  Mem  de  la  Soc.  de  Chir.  de 
Paiis,  1881,  p.  99.  (-See  also  St.  Thomas's  Hosp.  Museum,  No.  Q  127  and 
No.  Q  129.  and  a]so  lancet,  May  24,  1884.^ 


CW.  1 TRIGIAL    S  TRIC  T  URE. 


ill 


of"  stenosis  in  these  instances  varies.  In  some  of  the  cases  the 
valve  just  admitted  the  point  of  the  finger,  in  another  it 
would  only  give  passage  to  a  No.  9  catheter,^  and  in  two 
examples  it  was  entirely  obliterated.!     In  this  instance  the 

b 


Fig.  91. — Stricture  of  the  Ileo-cascal  Valve. 

a,  csecum  not  laid  open  ;  6,  iletira  laid  open  ;  c,  cicatrices  of  ulcers  ;  c1,  puckered  iiiuftous 
membrane.  The  valve,  which  was  reduced  to  the  size  of  a  No.  12  catheter,  is  occu- 
pied by  a  piece  of  whalebone. 


ileum  and  caecum  communicated  by  means  of  a  fistulous 
opening,  and  the  closure  of  the  valve  proved  a  matter  of 
comparatively  little  importance. 

*  Path.  8oc.  Trans.,  vol,  xxi.,  p.  171. 

t  Berlin,  klin.  Wochens.,  No.  26,  p.  093,  June,  1879  ;  find  Path.  Soc.  Trans., 
18S9,  p.  107. 


218  STltlCTURE    OF    THE    INTESTINE. 

Example^'  of  stricture  of  the  ileo-csecal  valve  are  shown  in 
Figs.  86,  90  and  91. 

(B)  Stricture  After  Strangulated  Hernia.— The  stricture 
which  may  form  in  a  piece  of  the  intestine  that  has  been 
involved  in  a  strangulated  hernia  is  due  to  cicatrisation  and 
follows  upon  ulceration  or  limited  gangrene  of  the  involved 
bowel.  I  have  found  eleven  recorded  examples  of  this  stricture, 
in  addition  to  several  specimens  to  be  seen  in  some  of  the 
London  museums.  It  has  followed  upon  both  inguinal  and 
femoral  rupture,  and  has  produced  symptoms  of  obstruction 
at  a  period,  after  the  relief  of  the  hernia  by  taxis  or  operation, 
varying  from  a  few  days  to  "  some  years."  The  larger  number 
of  cases  have  been  noted  between  one  and  six  months  after 
the  reduction  of  the  hernia.  In  nine  cases  the  ileum  was 
involved  ;  in  two  the  jejunum.  In  one  instance  one  inch 
and  a  half  of  the  bowel  was  found  contracted  and  thickened.^ 
In  other  examjiles  the  stricture  was  of  very  limited  extent 
and  annular  as  if  a  narrow  tape  had  encircled  the  bowel. 
In  one  case  two  strictures  are  described.t  In  one  example 
the  stenosed  part  would  only  admit  a  goose-quill,:]:  and  in 
another  water  would  only  pass  through  it  in  drops. §  In 
one  specimen II  a  large  valvular  fold  of  mucous  membrane 
passed  across  the  lumen  of  the  gut  at  the  strictured  part. 

In  a  case  recorded  by  Dr.  N.  Pitt  the  seat  of  the  stricture 
was  surrounded  by  considerable  thickening  and  cicatrisation. 
In  this  example  symptoms  appeared  five  days  after  the 
reduction  of  a  femoral  hernia  which  had  been  down  seven 
days.TI 

It  would  appear  from  an  account  of  examples  of  this 
stricture  furnished  by  Garre^^  and  Maastt  that  it  is  usually 
due  to  necrosis  of  the  mucous  layer  of  the  gut. 

(C)  Stricture  After  Injury. — The  commonest  example 
of  this  type  of  stricture  is  that  due  to  operation  upon  the 
bowel.  Of  this  trouble  modern  surgery  has  provided 
numerous  examples.  Stricture  has  followed  upon  extensive 
suturing  of  the  bowel,  upon  excision  of  bowel,  and  upon 
the  operation  of  short  circuiting,  or  lateral  anastomosis.  I 
have  recorded  an  instance  in  which  the  operation  of  short 
circuiting  performed  in  the  sigmoid  flexure  with  the  largest 

*  Med.  Times  and  Gazette,  vol.  i..  1872,  p.  363. 
t  Br>t.  Med.  Journ.,  Oct.  9,  1897.  p.  9ol. 
X  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1880,  p.  706. 
§  Path.  Soc.  Trans.,  vol.  iii.,  p.  95. 

!|  Middlesex  Hosp.  Museum,  No.  114,  viii. ;  aec  also  Guy's  Hospital  Museum, 
N'o.  '2.507  (36). 

II   Pnth.  Soc.  Trans.,  1891,  p.  119. 

**   Beitraoje  z.  Klin.  Chir.,  1892.  vol.  ix.,  p.  187. 

tt  Deuf.  Med.  Wochen.,  1895,  i.,  p.  36.5. 


STRICTUBE    AFTER    INJURY.  219 

size  of  Murphy's  button  led  to  a  stricture  which  would 
scarcely  admit  the  little  finger.  It  is  needless  to  say  that 
the  majority  of  the  examples  of  stricture  due  to  operation 
are  provided  by  the  lesser  bowel. 

I  find  records  of  some  six  cases  *  of  stricture  which  were 
evidently  due  to  cicatrisation,  following  accidental  injury  to 
the  bowel.  The  patients  were  males,  and  the  ages  ranged 
from  twenty-four  to  sixty-five.  In  four  cases  the  jejunum 
was  involved,  and  in  two  the  ileum.  Symptoms  of  obstruc- 
tion appeared  between  four  weeks  and  four  months  of  the 
receipt  of  the  injury.  In  each  instance  the  lesion  consisted 
of  a  violent  blow  or  fall  on  the  abdomen,  or  the  patient  was 
ridden  over.      In  none  of  the  examples  was  there  a  wound. 

In  one  case  reported  by  Pouzet  the  stricture  would 
hardly  admit  a  probe,  and  was  narrow  and  ring-like.  In 
another  instance  the  stricture  was  represented  by  a  con- 
traction which  occupied  no  less  than  six  inches  of  the 
jejunum. 

In  this  type  of  stricture  adhesions  are  not  uncommon 
I  have  not  included  under  this  heading  cases  in  which 
a  stricture  has  followed  as  a  result  of  ulceration  due  to 
impacted  gall  stones  t  or  foreign  bodies. 

Ax  Unclassified  Specimen. — It  may  here  be  convenient 
to  draw  attention  to  a  specimen  in  the  museum  of  University 
College  Hospital,  which  is,  so  far  as  I  can  ascertain,  unique. 

A  drawing  of  the  specimen  is  shown  in  Fig.  92. 

It  shows  a  portion  of  the  small  intestine,  the  lumen  of 
which  has  been  at  one  point  remarkably  narrowed.  The 
narrowing  is  due  to  an  even  folding-in  of  all  the  coats  of 
the  bowel  towards  the  lumen  of  the  tube. 

This  infolding  involves  only  a  portion  of  the  circum- 
ierence  of  the  intestine.  The  infolded  parts  appear  normal 
on  section,  save  for  a  little  thickening  of  the  mucous 
membrane.  The  fold  is  rendered  permanent  by  ad- 
hesions between  the  two  opposed  serous  surfaces.  The  in- 
folding is  towards  the  mesenteric  attachment  of  the  bowel. 
In  the  mesentery  are  certain  enlarged  and  inflamed  glands 
in  close  contact  with  the  gut.  The  specimen  Avas  obtained 
from  the  body  of  a  man  who  died  of  intestinal  obstruction. 

*  Reference  may  be  made  to  the  following  : 

Pouzet  quoted  bv  Xothnagel:  Die  Erkrankungen  des  DaiTnes.    Vienna, 
1896. 

Path  See.  Trans.,  vol.  iv.,  p.  156. 

Bull,  dela  Soc   Anat.,  1877,  p.  86. 

Mygind;  Annual  of  the  Univera.  Med.  8ci.,  1S92,  vol.  iii.,  (J-6G. 

Gu\'s  Hosp.  Reports,  ISoS. 

Edhn.  Med.  nnl.  Surg.  .Jom-ti.,  vol.  xliv.,  p.  281, 
t  Sec  Path.  Soc.  Trans.,'  18.38,  p.  30.3. 


220  STBIGTUBE    OF    THE    INTESTINE. 

Of  the  nature  of  the  obstruction  in  this  case  it  is 
difficult  to  speak.  It  is  certainly  not  a  stricture  in  the 
proper  sense. 

The  gut,  if  viewed  laterally,  does  not  present  evidences 
of  acute  bending.  It  can  only  be  surmised  that  the  con- 
dition is  associated  with  the  mesenteric  gland  disease,  and 


Pio.  92.— stenosis  due  to  in-turning  of  the  Intestinal  Wall,  the  result  of  Mesenteric 

Gland  Disease. 

that  the  little  local  peritonitis  excited  had  spread  from  the 
disordered  lymph  glands.  Above  the  stenosed  part  is  a 
considerable  pouch. 

11.  The  Cancerous  Stricture. — Carcinoma  of  the  intes- 
tine may  be  either  primary  or  secondary.  As  a  secondary 
growth  it  may  appear  either  by  metastasis  or  by  exten- 
sion from  neighbouring  parts.  So  far  as  surgical  practice 
is  concerned,  the  growth  causing  obstruction  or  definite 
intestinal  symptoms  is  usually  primary.  The  metastatic 
form  need  not  be  considered  here. 

Carcinoma  may  occur  in  any  part  of  the  intestinal  canal 
from  the  pylorus  to  the  anus. 

There  was  a  time  when  a  great  many  different  forms 
of  cancer  were  described  as  occurring  in  the  bowel.  Accounts 
were  furnished  of  scirrhus  cancer,  of  encephaloid  or  medullary 
cancer,  and  of  villous  cancer. 

The  evidence  is  now  practically   conclusive  which  shows 


CAXCEROUS    STRICTURE.  221 

that  pviinaiy  cancer  of  the  intestinal  canal  conforms  to  one 
type  only — that  of  cylindrical-celled  epithelioma,  or  cyHn- 
droma."^ "  This  form  of  carcinoma  may  undergo  colloid 
changes,  and  thus  it  happens  that  "  colloid  cancer  "  is  met 
with  in  the  bowel. 

Cjdindrical  epithelioma  of  the  bowel  does  not  present 
itself  under  a  uniform  aspect.  It  assumes  many  forms  and 
appearances,  and  has  thus  given  rise  to  the  belief  among 
the  early  pathologists  that  many  ditferent  varieties  of  cancer 
■were  met  with  in  the  bowel. 

This  exclusiveness  in  the  matter  of  cancer  in  this  situa- 
tion is  rendered  more  marked  by  the  fact  that  metastatic 
deposits  of  carcinoma  very  rarely  occur  in  the  intestine. 
When  they  do  occur  they  seldom  cause  obstruction. 

The  bowel  may  be  invaded  by  malignant  disease,  which 
has  spread  to  it  from  a  carcinoma  in  a  neighbouring  organ, 
but  the  circumstance  is  uncommon.  For  example,  Mr. 
McCarthy  reports  a  case  of  cancer  of  the  splenic  Hexure  in 
which  the  disease  had  spread  to  the  bowel  from  a  primary 
growth  in  the  stomach.  Intestinal  obstruction  had  been 
prcduced.t 

Into  the  microscopical  character  of  the  epithelioma  of 
the  bowel  it  is  unnecessary  to  enter  in  any  detail. 

This  subject  has  been  most  exhaustively  treated  by 
Harrison  Cripps,  Hauser,  and  many  others. 

The  morbid  changes  commence  in  the  cylindrical  cells 
of  Lieberktihn's  glands,  and  a  new  growth  appears  in  the 
deeper  parts  of  the  mucous  membrane  which  reproduces 
in  a  more  or  less  exact  manner  the  glandular  tissue  of  the 
bowel.  The  growth  consists  of  glandular  recesses  lined  with 
columnar  cells,  and  embedded  in  a  stroma  of  connective 
tissue.  In  the  very  earliest  stages  it  is  not  possible  to 
distinguish  the  carcinoma  from  an  adenoma  of  the  bowel. 
Very  soon,  however,  the  glandular  epithelium  makes  its  Avay 
through  the  limiting  membrane  of  the  gland,  and  through  the 
muscularis  mucosse  and  runs  riot  in  the  submucous  layer, 
and  spreads  as  it  likes  among  the  muscular  coats  of  the 
bowel.  Even  in  these  unfamiliar  districts  the  growth  re- 
tains its  likeness  to  glandular  tissue,  a  likeness  made  a  little 
indistinct  by  exuberance  of  unrestrained  growth  and  by 
concomitant  decay.  It  is  this  masquerade  of  a  normal 
structure  among  unaccustomed  tissues,  this  hideous  mimicry 
of  the  simple  gland  which  constitutes  cancer. 

*  An  early  assertion  of  this  fact  was  made  bv  M.  Haussmann ;    Cancer  de 
I'Intestin.     These  de  Paris.  1882.     No.  228. 
t  Med.-Chir.  Trans.,  1872. 


222  STRICTURE    OF    THE    INTESTINE. 

The  progress  of  the  growth  is  marked  by  rapid  spreading 
in  some  parts,  by  degeneration  in  others,  by  contraction,  by 
ulceration,  by  sloughing,  by  htemorrhage,  these  being  the 
circumstances  which  attend  all  cancerous  growths. 

If  the  progress  be  rapid  and  the  cell  elements  be  excessive, 
the  growth  is  soft.  If,  on  the  other  hand,  the  cells  be — ^for 
any  reason — less  in  evidence,  and  the  supporting  stroma 
be  conspicuous  and  well  developed,  then  the  growth  is  more 
or  less  hard. 

For  some  little  time  the  tumour  extends  beneath  unbroken 
mucous  membrane  as  a  nodule  or  flattened  and  irregular  disc. 
The  mucous  membrane  soon,  however,  gives  way,  and  the 
growth  is  exposed,  to  exhibit  as  it  Avills  its  peculiarities  of 
ulceration,  of  sloughing,  or  of  bleedmg. 

If  the  neoplasm  increases  rapidly  and  steadily  a  promi- 
nent tumour  is  formed,  which  may  in  time  even  block 
up  the  bowel.  If,  on  the  other  hand,  the  growth  is  slow,  no 
actual  tumour  is  produced,  but  an  ill-detined,  flattened  patch 
of  malignant  tissue  is  found  to  be  creeping  around  the  bowel. 

Most  usually,  the  numerous  hordes  of  hurriedly-formed 
cells  undergo  degeneration,  and  the  connective  tissue  falls 
in  upon  the  spaces  which  they  have  occupied,  with  the 
result  that  the  growth  becomes  hard  and  tibrous  and 
unyielding,  and  by  its  contraction  forms  in  the  bowel  wall 
an  annular  stricture. 

While  the  central  part  of  the  growth  is  producing  a 
stricture  the  outskirts  may  be  growing  luxuriantly,  so  that 
the  rigid  ring  and  the  soft  and  rounded  tumour  may  be  met 
with  side  by  side.     {See  Fig.  93.) 

It  thus  happens  that  epithelioma  may  be  met  with  in 
the  bowel  under  at  least  three  different  aspects — viz.  as  a 
rounded  nodule,  as  a  flattened  plaque  involving  only  a 
portion  of  the  circumference  of  the  bowel,  and  as  an  annular 
contracting  deposit,  which  surrounds  the  bowel  like  a  ring. 

These  three  conditions  may  represent  stages  of  the  same 
growth.  It  may  appear  at  flrst  as  a  distinct  subnuicous 
nodule,  then  as  a  flattened  plaque,  and  lastly  as  a  stricture 
of  an  annular  type. 

The  conmionest  form,  however,  under  which  epithelioma 
of  the  intestine  presents  itself  to  the  surgeon  is  that  of  the 
annular  band  around  the  intestine.  Compared  with  this 
aspect  of  the  growth,  the  nodules  and  plaques  may  be  said  to 
be  comparatively  rare.  The  ring-like  formation  affords  an 
example  of  the  neoplasm  directed  in  its  course  by  the  blood- 
vessels of  the  y.)art,  which  here  follow  a  course  transversely 
to  the  long  axis  of  the  bowel. 


CAKCEROUS    STRICT I'R K. 


22.3 


The  appearance  of  these  strictures  is  very  typical  The 
gut  at  the  stenosed  part  appears  to  be  very  suddenly  con- 
stricted, as  if  a  piece  of  cord  had  been  drawn  tightly  about 
it.     The  stricture  is  usually  quite  annular,  but  insignificant 


Fig.  93. —Epithelioma  of  the  Colon. 
a,  tumom- ;  6,  site  of  lumen  of  bowel ;  c,  appendices  epii'loicje. 


in  width,  comparatively  little  of  the  gut,  as  measured  along 
its  long  axis,  being  involved.  The  peritoneum  about  the 
stenosed  part  is  often  thickened;  the  bowel  is  not  infrequently 
adherent,  and  now  and  then  distorted  or  bent  upon  itself 


224 


STRICTURE    OF    THE    INTESTINE. 


If  the  dilated  gut  above  the  narrowed  strait  be  cut  across, 
a  bird's-eye  view  of  the  stricture  can  be  obtained. 

The  gut  narrows  abruptly  and  the  stenosed  part  looks  like 
the  waist  of  an  hour-glass.  The  inner  surface  of  the  hard 
ring  is  usually  ulcerated  and  ragged  or  sloughy-looking. 
Above  and  below  the  stricture  the  growth  spreads  out  upon 
the  uncontracted  bowel.  It  forms  an  ulcerated  surface, 
raised,  spongy-looking,  and  often  comparatively  smooth. 
This  terminates  in  a  pronounced  edge  which  stands  up  above 

the  normal  mucous  mem- 
brane as  a  raised,  rounded, 
everted  and  hardish  margin. 
Nothing  can  be  more  char- 
acteristic (Figs.  94  and  95.) 
There  are  many  varia- 
tions of  this  condition.  In 
some  instances  the  whole 
of  the  disease  may  be  so 
limited  that  it  could  almost 
be  covered  by  a  wide  v/ed- 
ding  ring.  The  gut  is 
pinched  in  suddenly  and 
yet  the  mucous  membrane 
on  either  side  of  it  is  appar- 
ently normal.  This  condi- 
tion may  exist  and  yet  a 
wide  tube  like  the  colon  be 
almost  closed.     (Fig.  95.) 

In  other  examples  the 
growth  around  an  annular 
stricture  may  be  quite  considerable  and  involve  some  inches 
of  the  bowel.  It  may  appear  as  an  irregular  patch  or  as 
a  nodule  or  nodules  or  as  a  kind  of  funoating:  mass.  The 
ulceration  may  be  deep  and  excessive.     (See  Fig.  96.) 

The  degree  of  stenosis  varies.  The  narrowed  part  may 
admit  the  thumb  or  it  may  be  so  constricted  as  barel}''  to 
admit  a  goose-quill.  In  many  specimens  I  have  seen, 
nothing  but  a  probe  could  be  j)assed,  and  in  many  reported 
specimens  the  gut  is  described  as  "  almost  closed."  As  these 
conditions  are  quite  common  in  the  colon,  some  idea  ot 
the  immense  power  of  contraction  of  the  growth  is  to  be 
obtained. 

Indeed  the  tendency  of  malignant  disease  within  the 
bowel  IS  distinctly  to  produce  very  narrow  and  very  rigid 
strictures,  strictures  which  persistently  contract.  There  is 
evidence  that  now  and  then  the  narroAved  passage  is  opened 


Fig.   94.— Epithelioma  of  Colon.      BircVs- 
eye  view  of  the  Interior  of  the  Bowel. 

At  a,  a  triangular  piece  of  the  intestine  has  been 
cut  away. 


a  A  NCEROUS    STJilCJ  TUR  E. 


lip  by  extensive  sloughing  of  the  growth,  hut  if  the  patient 
survive  it  is  almost  sure  to  close  up  again. 

There  is  no  doubt  but  that  in  all  epitheliornata  of  the 
bowel  early  ulceration  is  a  rule  to  which  there  are  few 
exceptions. 

It  is  not  always  by  a  ring-like  band  that  the  gut  is 
narrowed.  The  growth  may 
infiltrate  the  bowel  wall  over 
a  considerable  area,  with  the 
result  that  the  intestine  for 
one  or  more  inches  is  con- 
verted into  a  solid  tube  Avith 
but  a  moderately  narrowed 
lumen. 

In  a  certain  series  of 
cases  it  cannot  be  said  in  a 
precise  sense  that  the  bowel 
is  actually  constricted.  In 
these,  examples  the  growth 
appears  as  a  rounded  or  ir- 
regular tumour,  which  is 
much  softer  than  the  smaller 
and  contracting  growths, 
and  which  may  more  or  less 
completely  plug  the  lumen 
of  the  gut.  Such  a  tumour 
may  even  hang  from  the 
bowel  wall  as  a  polypoid  ex- 
crescence. This  condition 
was  met  with  in  a  case  re- 
ported upon  by  Dr.  Dalton^ 
and  already  alluded  to  in  the 
chapter  on  intussusception. 

Now  and  then  the  growth  has  appeared  as  a  huge  cauli- 
flower mass  bulging  into  the  gut  and  occupying  its  lumen. 
In  other  instances  the  cancer  is  represented  by  an  indistinct 
mass  rendered  shapeless  and  nondescript  by  ulceration  and 
extensive  sloughing. 

Finally  the  gut  may  be  closed  neither  by  the  contracting 
of  the  growth  nor  by  its  exuberant  budding  out  into  the 
bowel,  but  stenosis  may  depend  upon  the  bending  or  twisting 
of  the  intestine  at  the  seat  of  the  malignant  growth.  This 
condition  may  be  due  to  peritoneal  adhesions  or  to  the 
extension  of  the  growth  into  the  tissues  beyond  the  bowel  or 
to  the  traction  of  some  organ  to  which  the  diseased  gut  has 

.     .  *  Piilh.  Soc.  Trans.,  1890,  p.  122. 

P 


Fig.  9.5. — Almost  complete  occlusiou  of 
the  Colon  by  a  very  small  Carcinoma. 

(.Royal  Coll.   of  Surg.  Mus.,  No.  2n32). 


226 


ST  RIG  TUBE    OF    THE    INTESTINE. 


become  attached.  I  have  found  the  intestine  much  bent  upon 
itself  owing  to  the  contraction  of  an  epitheHoma  which  had 
invaded  only  a  part  of  the  circumference  of  the  bowel,  or  to 

the  unequal  shrink- 
ing of  a  growth 
which  had  described 
the  circuit  of  the 
tube. 

The  association 
of  intussusception 
with  cancer  of  the 
bowel  has  been  dealt 
with  on  page  183. 

When  an  epi- 
thelioma of  the 
bowel  has  under- 
gone colloid  changes 
an  appearance  is 
produced  which  is 
so  characteristic  that 
it  can  scarcely  be 
mistaken. 

One  of  the  most 
admirably  described 
examples  of  colloid 
cancer  of  the  bowel 
has  been  given  by 
Dr.  A.  Kanthack.-^ 

The  patient  was 
a  lad  of  seventeen. 
He      died      twelve 
months     after     the 
onset   of  symptoms 
of     intestinal      ob- 
struction. These 
symptoms  appeared 
with     such     acute- 
ness    that    a    right 
lumbar        colotomy 
was        performed 
ten    days    after    the    first    symptom    had   made    itself    evi- 
dent.    During   these   ten   days  nothing  was   passed   by  the 
rectum. 

The  following  is  an  abstract  of  the  appearances  presented 
at  the  post-mortem  examination  : — 

*  Path.  Soc.  Trans.,  1897,  p.  99. 


P         6. — Cylindrical  Epithelioma  of  the  Transverse 
Colon,  forming  an  Annular  Stricture. 

In  the  gut  above  the  growth  is  a  circular  ulcer, 
the  floor  ot  whicli  is  formed  solely  of  the  serous  iiiem- 
Lrane.     (PMyal  Coll.  of  Surg.  Mus.,  No.  2529,  A.) 


OANCEROUS    S'TIilCTURE.  227 

"The  visceral  and  parietal  peritoneum  was  studded  all  over  with 
small  nodules  of  new  growth  which  presented  a  colloid  appearance.  In 
the  region  of  the  ascending  colon  there  was  a  mass  of  new  growth, 
exceedingly  dense  in  parts  but  soft  and  colloid  or  myxomatous  in  others. 
.  .  .  The  growth  had  involved  the  cyecum  considerably,  and  had  spread 
along  the  bowel  as  far  as  the  hepatic  flexure  and  the  gall  bladder,  the 
walls  of  which  were  infiltrated  by  it.  There  was  almost  complete 
obstruction  of  the  lumen  of  the  bowel.  There  were  no  secondary 
deposits  in  the  lungs  or  liver.  .  .  .  The  growth  involved  the  first  five 
or  six  inches  of  the  ascending  colon,  the  cfeoum  and  ileo-c«cal  valve, 
and  the  lower  four  inches  of  the  ileum.  The  whole  circumference  of 
the  intestine  was  infiltrated  by  the  growth,  which,  when  fresh,  had  a 
markedly  colloid  or  myxomatous  appearance,  the  main  mass  being 
situated  about  five  inches  above  the  ileo-csecal  valve.  At  this  point 
the  lumen  of  the  gut  was  almost  completely  occluded.  Near  the 
caecum  the  growth  had  assumed  considerable  dimensions,  and  the  wall 
of  the  ascending  colon  on  section  presented  here  a  nearly  circular 
nodule  of  new  growth  about  one  inch  in  diameter  ;  it  was  firm  outside, 
but  had  undergone  colloid  changes  in  the  centre.  The  mucous  mem- 
brane covering  the  growth  Avas  deeply  ulcerated.  The  cjecum  had 
been  converted  into  an  almost  solid  mass  with  a  lumen  of  about  the 
size  of  a  slate  pencil.  The  wall  of  the  ileum  was  about  one -third  of  an 
inch  thick.  The  growth  had  aftected  all  the  coats  of  the  bowel.  The 
most  striking  feature  was  the  colloid  or  myxomatous  character  of  the 
growth." 

The  microscopic  examination  showed  that  the  tumour  was 
a  cohnnnar-celled  carcinoma  which  had  become  colloid. 

Carcinoma  of  the  intestine  is  met  with  as  a  sohtary  sfrowth. 
To  this  rule  there  are  exceedingly  few  exceptions.  Dr.  Pye 
Smith^  records  a  case  in  which  there  were  two  cancerous 
strictures  in  the  duodenum,  one  close  to  the  pylorus  and  one 
three  inches  lower  down.  There  were  secondary  deposits  in 
the  liver.  Symondsf  reports  a  case  where,  in  addition  to  a 
cancerous  stricture  in  the  sigmoid  flexure,  there  was  a  second 
stricture  in  the  ascending  colon,  which  had  caused  death. 

Weichelsbaumt  records  an  instance  in  which,  in  addition 
to  numerous  polypi  in  both  the  large  and  small  intestine,  there 
were  three  separate  deposits  of  cancer:  one  in  the  caecum, 
another  in  the  transverse  colon,  and  a  third  in  the  rectum. 

Among  the  complications  of  carcinoma  of  the  bowel,  the 
following  may  be  mentioned  : — 

The  lymphatic  glands  become  implicated ;  but  their 
infection  is  slow,  and  in  cancer  of  the  colon  it  is  often  very 
slow.  .  In  malignant  disease  of  the  lesser  intestine  gland 
implication  appears  earlier  than  it  does  in  like  trouble  in  the 
colon.      In  not  a  few  examples  of  cancer  of  the  colon  I  have 

*  Path.  Soc.  Trans.,  1894,  p.  36.      See  also  ca.ses  of  probable  miiltiple  stricture 
due  to  c  rcinoma  detailed  by  Dr.  Carrington  in  Path.  Soc.  Trans.,  1886,  p.  244. 
t   Brit.  Med.  Journ.,  1893.  vol.  i.,  p.  638. 
:J:  Annual  of  the  Uni\'ersal  'SleA.  8oi.,  189.5,  vol.  i.,  D-o7. 


228  STRICTURE    OF    THE    INTESTINE. 

failed  to  find  any  infected  glands  in  cases  which  have  lasted 
for  many  months. 

Secondary  deposits  are  met  with  as  in  carcinoma-  else- 
where. In  cancer  of  the  bowel,  the  organs  affected  are 
most  usually  the  liver,  the  peritoneum,  and  the  kmg — the 
liver  especially  and  most  commonly. 

The  growth  is  often  complicated  by  peritoneal  adhesions 
of  varying  density,  which  may  bind  it  down,  bend  or  distort 
it,  or  fix  it  to  some  neighbouring  organ  or  to  the  abdominal 
parietes.  The  sigmoid  flexure  has  been  found  adherent  to 
the  ca3cum.  I  have  known  the  adhesions  around  a  cancer 
of  the  colon  occlude  a  coil  of  small  intestine  which  had 
become  involved  in  the  adhesions,  although  not  invaded 
by  the  primary  growth.  Over  and  over  again,  however, 
carcinoma  of  the  bowel  will  run  its  whole  course  without 
causing  adhesions  of  any  kind,  and,  indeed,  adhesions  of 
any  degree  are  exceptional. 

The  malignant  disease  may  occasionally  spread  from  the 
bowel  and  invade  adjacent  parts,  and  in  rare  instances  the 
spread  of  the  growth  beyond  the  limits  of  the  bowel  may 
be  quite  considerable. 

The  cancerous  growth  may  invade  the  bladder,  and  a 
fistulous  communication  be  established  between  that  viscus 
and  the  bowel,  or  an  opening  may  be  made  into  the  vagina. 

A  fistulous  opening  may  be  effected  into  a  neigh- 
bouring coil  of  intestine.  For  example,  in  a  case  recorded 
by  Mr.  R.  Johnson^  a  carcinoma  of  the  transverse  colon 
had  effected  a  communication  with  the  ileum. 

In  a  case  reported  by  Joncherest  a  communication 
was  opened  up  between  the  colon  and  the  stomach. 
Two  specimens  of  such  communication  are  in  the  museum 
of  the  Royal  College  of  Surgeons  (Nos.-  2531  and  2531  A. 
Carcinoma  of  the  bowel  may  lead  to  an  abscess  outside 
the  bowel  walls.  This  abscess  may  assume  considerable  pro- 
portions, and  may  biu'row  extensively.  In  one  case  under 
my  care  an  abscess  starting  from  a  cancerous  growth  in 
the  sigmoid  flexure  made  its  way  through  the  sacro-iliac 
articulation  and  appeared  on  the  buttock. 

I  met  with  an  instance  of  epithelioma  of  the  ctecum  in 
which  an  extensive  abscess — supposed  to  be  due  to  disease 
of  the  appendix — was  the  first  sign  of  the  malady.  The 
abscess  starting  from  an  epithelioma  of  the  bowel  may 
extend  in  more  directions  than  one,  and  may  be  evacuated 
at  several  points  which  may  be  at  some  distance  from  one 

*  Path.  Soc.  Trans.,  1889,  p.  110. 

t  Annual  of  the  Universal  Med.  Sci.,  1895,  vol.  i.,  D  57. 


GAXGEBOUS    STEIGTURE.  229 

another.  Tlirougli  these  sinuses  tieeal  matter  may  be  dis- 
charged. In  a  case  of  cancer  of  the  rectum  in  which 
a  colotomy  had  been  advised  by  me  and  decHned  by  the 
patient  an  abscess  formed,  which  in  due  course  discharged 
above  Poupart's  hgament.  Fcecal  matter  escaped  from  it, 
and  in  time  all  the  motions  were  passed  through  this  natural 
colotomy  opening  to  the  great  relief  of  the  patient. 

I  have  seen  one  instance  or  so  in  which  the  amount  of 
pus  in  the  abscess  has  been  trifling,  but  the  suppurating 
cavity  has  been  so  distended  with  gas  as  to  form  a  huge 
gaseous  tumour,  tympanitic  in  all  parts  and  hable  to  varia- 
tions in  size.  Dr.  Dickinson"^  has  recorded  a  case  in  which 
a  gaseous  tumour  connected  with  a  cancer  of  the  sigmoid 
flexure  was  of  quite  enormous  size,  and  appeared  early  in 
the  course  of  the  disease.  In  all  these  examples  of  gaseous 
tumour  there  is  a  communication  with  the  lumen  of  the 
bowel,  and  an  incision  into  the  cavity  is  usually  followed 
by  an  escape  of  fteces. 

In  the  place  of  a  definite  abscess  there  may  be  a  diffuse 
and  foul  cellulitis,  with  subcutaneous  emphysema,  sloughing, 
and  rapid  death  from  septictemia. 

The  general  effects  of  a  stricture  of  the  bowel  upon  the 
intestine  above  it  have  already  been  dealt  with  on  page  1(3. 

The  Condition  of  the  Stricture  in  its  Relation  to 
THE  Clinical  Aspect  of  the  Case.— The  stricture  at  the 
time  of  death  ma}^  be  wide  enough  to  admit  the  tip  of  the 
forefinger ;  on  the  other  hand,  it  may  be  so  narrow  that  water 
will  merely  trickle  through  it  in  drops,  or  it  will  admit  only 
a  probe  or  a  goose-quill.  As  a  rule,  the  narrowest  strictures 
are  met  with  in  the  small  intestine,  although  there  are  cases 
of  stenosis  of  the  colon  where  the  obstructed  part  has,  at  the 
time  of  death,  only  allowed  a  common  probe  to  pass.  Such 
extreme  cases  are,  however,  rare  in  the  larger  bowel.  A 
stricture  can  attain  to  narrow  dimensions  without  producing 
a  rapidly  fatal  result  when  the  contents  of  the  part  of  the 
bowel  that  it  involves  are  fluid.  This  is  one  reason  why 
narrower  strictures  are  more  possible  in  the  small  than  in  the 
large  intestine.  In  Fig.  82  is  shown  a  narrow  stricture  of  the 
ie;junum  that  never  caused  obstruction  symptoms,  the  patient 
dying  Avith  diarrhoea.  Messrs.  Coupland  and  Morris  in  their 
monograph  allude  to  a  case  of  annular  stenosis  of  the  jejunum 
that  was  so  narrow  as  only  to  admit  a  No.  7  catheter,  and 
yet  the  patient  presented  no  intestinal  symptoms  during  life. 
In  like  manner,  if  the  contents  of  the  colon  be  fluid,  strictures 

*  Path.  .Soc.  Trans.,  1882,  p.  161.     -' 


230  STRICTURE    OF    THE    INTESTINE. 

of  that  gut  wliicli  are  comparatively  narrow  may  cause  no 
symptoms  of  obstruction.  Such  patients  die  with  severe  and 
persisting  diarrhcea.  Many  cases  have  been  recorded  where 
this  part  of  the  bowel  at  the  autopsy  has  appeared  almost 
quite  blocked  by  a  cancerous  new  growth,  and  yet 
the  patient  has  presented  no  symptoms  of  obstruction. 
The  contents  of  the  colon  have  remained  in  a  fluid  con- 
dition, and  death  has  followed  upon  a  long-abiding 
diarrhoea. 

'\  he  precise  manner  in  which  a  stricture  of  the  intestine 
brings  about  the  death  of  a  patient  is  by  no  means  the  same 
in  every  case. 

In  some  instances  the  stricture  becomes  narrower  and 
narrower,  the  obstruction  becomes  by  slow  degrees  more  and 
more  complete  until  at  last  it  causes  death,  after  following 
a  chronic  and  lingermg  course.  In  other  cases  the  stricture, 
having  obstructed  the  bowel  to  a  certain  extent,  appears  to 
undergo  no  further  contraction,  but  the  patient  dies  worn  out 
by  the  long- continued  abdominal  troubles,  or  succumbs  to  an 
increasing  marasmus.  In  cases  of  malignant  disease  also  the 
effect  of  the  morbid  growth  upon  the  patient's  general  con- 
dition must  not  be  overlooked.  There  are  cases  that  for  a 
while  adopt  a  lingering  progress,  and  then  end  somewhat 
more  abruptly.  That  is  to  say,  for  some  considerable  time 
the  malady  may  present  the  symptoms  of  a  chronic  obstruc- 
tion, and  the  fatal  issue  be  brought  about  by  an  attack  of 
acute  obstruction.  Instances  of  this  kind  depend  upon  many 
different  pathological  conditions.  Thus  a  plug  of  hard  faecal 
matter  may  have  blocked  up  a  stricture  that  had  of  itself 
caused  no  very  serious  amount  of  obstruction."^  Or  this 
blocking  of  the  stenosed  part  may  have  been  brought  about 
by  some  foreign  substance.  Thus  in  a  case  reported  by  Dr. 
Peacock  a  dry  raisin  was  found  impacted  in  the  stricture,t 
while  in  another  specimen  the  final  occlusion  of  the  already 
narrowed  bowel  had  been  brought  about  by  a  cherry  stone.J 
In  other  instances  folds  of  mucous  membrane  from  the  gut 
above  the  stenosed  part  may  so  fall  across  the  orifice  of  the 
stricture  as  to  close  it  like  a  valve.  In  these  cases  water  may 
be  injected  with  ease  from  below,  but  only  with  much  diffi- 
culty from  above.  To  cases  such  as  these  must  be  added  that 
extensive  series  where  the  small  intestine  at  the  seat  of  the 
stricture  has  become  so  bent  as  to  have  its  lumen  more  or 
less  abruptly  occluded,  or  where  "kinking"  has  occurred,  or 

*  Dr.  riatt;  loucef.  vol.  i.,  1873,  p.  -12. 

t  Dr.  Peacock:  Path.  Soc.  Trans.,  vol.  xiii.,  p.  137. 

X  Si.  Earl.'s  Hu.~p.  Museum,  No.  2017- 


SITE    OF    THE    8  TRIG  TUBE.  231 

where  the  narrowed  bowel  has  become  still  more  occluded  by 
adhesions  and  by  matting  of  its  coils  together. 

In  stricture  of  the  sigmoid  flexure,  moreover,  an  acute 
termination  to  the  case  is  by  no  means  uncommon.  The 
greatly  distended  "  flexure "  becomes  bent  upon  itself  and 
thereby  occluded,  or  its  parts  are  so  arranged  that  a  volvulus 
is  produced,  or  the  extremity  of  its  loop  contracts  adhesions 
which  may  serve  further  to  narrow  the  lumen  of  the  bowel. 

The  Site  of  the  Non- congenital  Stricture  of  the 
Bowel. — Strictures,  whether  due  to  cicatrisation  or  to  cancer, 
are  more  common  in  the  colon  than  in  the  small  intestine. 

Stricture  of  either  variety  may  be  found  in  any  part  of  the 
intestinal  canal.* 

In  the  small  intestine,  stricture  due  to  cicatrix  is  more 
common  than  that  due  to  carcinoma. 

Twenty-six  cases  of  stricture  of  the  small  intestine,  which 
I  collected  some  years  ago,  are  thus  distributed : — 

10  due  to  cancer. 

i  2  after  injury. 
16  due  to  cicatrisation  \  4  after  hernia. 
—  '  10  after  ulcer. 

26 

In  the  colon  (excluding  the  rectum)  stricture  due  to 
carcinoma  is  much  more  common  than  the  non-malignant 
stricture. 

Fifty- two  cases  of  stricture  of  the  colon,  including  the 
ileo-cfecal  valve,  but  excluding  the  rectum,  are  thus  dis- 
tributed : — 

33  due  to  cancer. 
16  due  to  cicatrisation. 
3  nature  not  defined. 

52 

If  the  rectum  be  excluded,  the  most  common  seat  ot 
stricture  of  the  colon  is  the  sigmoid  flexure,  and  the  com- 
monest form  of  stricture  there  is  cancer. 

Indeed,  60  per  cent,  of  all  strictures  of  the  large  intestine 
(excluding  the  rectum)  are  met  with  in  the  sigmoid  flexure. 
After  this,  in  order  of  frequency,  come  the  descending  colon, 
the    cpecum,   the    transverse    colon,    and,    last    of    all,    the 

*  Whittier  has  collected  thirteen  cases  of  "malignant  disease"  of  the 
duodenum  (Trans,  of  the  Assoc,  of  Amer.  Phys. ,  1889,  p.  292).  For  cancer  of 
the  smaller  intestine  sef-  cases  by  Morton  (Trans.  Path.  Soc,  1893,  p.  89)  and 
Eiegel  (Med.  Chron ,  1891,  p.  127).  Hawkins  gives  examples  of  cancer  of  the 
ileo-cajcal  valve  (Path.  Soc.  Trans.,  1891,  p.  132) ;  Stimson  (Annals  of  Surgery, 
1896,  p.  186)  and  Kelynack  (Path,  of  the  Verm.  Appendix,  p.  136)  give  examples 
of  caicinoma  of  the  vermiform  appendix. 


232  STRICTURE    OF    THE    INTESTINE. 

ascending  colon.  The  flexures  of  the  bowel  are  favourite 
sites.  In  101  consecutive  cases  of  cancer  of  the  large  in- 
testine occurring  at  University  College  Hospital,  the  seat  of 
the  disease  was  as  follows  :  Rectum  and  sigmoid  flexure,  94  ; 
descending  colon,  1 ;  splenic  flexure,  2  ;  transverse  colon,  1 ; 
hepatic  flexure,  2  ;  ileo-csecal  valve,  1."^ 

May  lard  has  collected  fifty  cases  of  cancer  of  the  colon, 
which  "he  finds  distributed  as  follows  :  Sigmoid  flexure,  13 ; 
descending  colon  and  splenic  flexure,  10  ;  transverse  colon 
and  hepatic  flexure,  4;  ascending  colon,  4;  caecum,  13,  and 
ileo-cjecal  valve,  b'.f 

III.  The  Congenital  Stkicture. — The  cases  which  are 
considered  under  this  heading  are  varied,  since  a  congenital 
stricture  may  be  found  in  any  section  of  the  intestine.  When 
the  stricture  is  complete— as  it  so  frequently  is — the  condition 
is  consistent  only  Avith  life  of  very  short  duration,  and  is 
amenable  only  to  but  very  imperfect  surgical  treatment.  When 
the  stricture  produces  merely  a  narrowing  of  the  bowel,  the 
clinical  phenomena  are  identical  with  those  which  attend 
other  and  more  common  stenoses  of  the  intestine,  and  the 
treatment  of  the  two  states  is  the  same. 

From  the  account  which  follows  I  have  excluded  any  re- 
ference to  congenital  defects  in  the  rectum  and  anus.  These 
abnormalities  include  the  most  common  and  the  most  easily  re- 
cognised varieties  of  congenital  atresia  of  the  alimentary  canal. 

Custom  has  very  properly  relegated  them  to  the  domain 
of  "  rectal  surgery."- 

I  have  dealt  on  page  19  with  the  congenital  rectal  diver- 
ticulum. 

Congenital  Stricture  of  the  Duodenum. — Congenital 
stricture  of  the  duodenum  is  most  common  in  the  "  second 
part"  of  that  intestine  and  just  above  the  entrance  of  the 
common  bile  duct.  It  is  in  this  position  that  the  congenital 
duodenal  diverticulum  is  found,  and  there  can  be  little  doubt 
but  that  both  the  pouch  and  the  stricture  depend  upon  de- 
velopmental defects  associated  with  the  hepatic  diverticulum 
{see  page  55).  The  same  association  of  a  diverticle  and  a 
possible  stricture  is  noticed  in  the  ileum  at  the  point  of  origin 
of  the  vitelline  duct  (see  page  52). 

The  stricture  may  be  of  any  degree.  The  gut  may  merely 
be  narrowed  and  no  symptoms  be  produced.  There  may  be 
a  septum  or  diaphragm  across  the  lumen  of  the  gut  which 
will  show  no  evidence  of  its  existence  from  the  outside. 

*  RaymondJohnson  ;  Path.  Soc.  Trant.,  1889,  p.  113. 
t  'Ih'e  .Surgery  of  the  Alimentary  Canal.     London,  1896. 


COXGESITAL    STRIGTUliE.  233 

This  septum  will  be  coiiiposi'd  of  the  mucous  and  circular 
muscular  coats  of  the  bowel  The  longitudinal  luuscular 
libres  take  little  or  no  part  in  its  production.  The  septum 
may  be  quite  complete,  and  so  produce  an  absolute  oc- 
clusion of  the  lumen  of  the  gut,  or  it  may  present  a 
perforation  in  the  centre  of  its  disc,  which  perforation 
may  vary  from  a  mere  pin-hole  to  an  aperture  large 
enough  to  alloAv  the  contents  of  the  stomach  to  escape 
without  hindrance. 

In  other  cases  the  bowel  wall  may  be  pinched  in  until 
the  lumen  is  greatly  narrowed"^  or  entirely  occluded. 

The  gut  at  the  seat  of  the  stenosis  may  be  reduced  to 
a  solid  cord  no  wider  than  a  No.  12  catheter,  and  may  be 
found  interposed  between  two  segments  of  apparently  normal 
intestine. 

In  fact,  the  gut  at  this  point  may  be  interrupted  by  a 
septum,  may  be  narrowed  or  may  be  completely  obhterated. 
Andersont  records  a  case  in  which  one  inch  of  the  duodenum 
close  to  the  pylorus  was  entirely  absent,  the  stomach  above 
and  the  bowel  below  each  ending  in  a  cul-de-sac.  Hobsonf 
also  gives  an  instance  in  which  the  duodenum  an  inch  from 
the  pylorus  ended  in  a  cul-de-sac,  free  from  all  direct  con- 
nection with  the  rest  of  the  small  intestine. 

Porak  and  Bernheim§  report  an  instance  in  which  the 
pylorus  was  much  contracted,  and  beyond  it  the  duodenum 
was  represented  by  a  blind  pouch,  which  ended  opposite  to 
the  pancreas. 

I^ess  frequently  the  stenosis  is  just  below  the  entrance 
of  the  common  bile  duct.  In  one  little  patient  I  saw,  in 
consultation  with  Dr.  Champneys,||  the  bowel  was  occluded 
by  a  complete  and  well-formed  septum  placed  immediately 
below  the  biliary  papilla.  In  this  instance  the  duodenum 
above  the  septum  was  so  dilated  as  to  be  as  large  as  the 
stomach.     {See  Fig.  97.)     The  child  had  lived  five  days. 

Another  place  in  which  the  duodenum  may  be  the  seat  of 
congenital  defects  is  at  the  duodeno-jejunal  bend.  Here,  as 
is  well  known,  the  bowel  suddenly  becomes  free,  and  here, 
in  the  human  subject  at  least,  considerable  changes  and 
adjustments  of  the  peritoneum  occur  during  the  process  of 
development.  The  intestine  at  this  particular  spot  may  be 
merely  narrowed,  or  its  lumen  may  be  completely  obliterated 
and   the  gut   reduced   to   a  narrow  and   solid  cord,  or   the 

*  Sei  case  bv  Emerson :   Xeir  York  Med.  Jon.rii.,  1890,  p.  153. 

t  Xew  York  Med.  Record,  1889,  p.  329. 

X  Brit.  Med.  .Journ.,  vol.  i.,  1893,  p.  637. 

4  Anii'ial  of  the  Universal  Med.  Scicnees,  189:^,  vol.  ii. 

ji   Path.  Soc.  Trans.,  1897,  p.  79. 


234 


STBICTUBE    OF    THE    INTESTINE. 


bowel  may  end  in  a  cul-de-sac  separated  entirely  from  the 
coils  of  lesser  intestine  beyond  it. 

Ducros  has  collected  eleven  examples  of  congenital 
stenosis  at  this  part  of  the  bowel. 

The  symptor)%s  in  these  cases  of  congenital  stricture  will 
obviously  vary  according  to  the  degree  of  the  stenosis. 

If  there  be  any  passage  at  all,  the  symptoms  may  be 
but  little  marked,  and,  if  they  assume  any  prominence,  will 
resemble  those  of  obstruction  of  the  pylorus.  When  the 
obstruction  is  complete,  the  child  dies  as  a  rule  within  five 


YiG.  97. — Congenital  Occlusion  of  the  Duodenum  by  a  Transverse  Septum. 

A  ligature  is  tied  round  the  gullet.  The  stomach  is  norninl  save  for  some  dilatation  of  its 
cardiac  end.  The  commencement  of  the  duodenum  is  enormously  dilated.  (T'rans. 
Fath.  Soc,  1897.) 

or  six  days.  For  the  first  twenty-four  hours  there  may  be 
no  symptoms  of  any  kind,  and  the  infant  may  take  nourish- 
ment well.  Then  sickness  commences,  and  in  time  all  that 
is  taken  is  rejected.  If  the  obstruction  be  above  the 
entrance  of  the  common  duct,  no  bile  appears  in  the  vomit ; 
if  it  be  below,  bile  is  present,  and  often  in  large  quantity. 
Meconium  is  passed.  Very  soon  there  is  obvious  dilatation 
of  the  stomach,  and  the  contraction  of  this  viscus  gives  rise 
to  colicky  pains,  as  evidenced  by  the  child's  cries  and  the 
drawing  up  of  its  legs.  Between  these  attacks  the  child 
may  sleep  comfortably.  By  the  fourth  day  I  have  been 
able  to  see  very  distinctly  through  the  parietes  the  con- 
tractions of  the  dilated  stomach  moving  from  left  to  right. 
Jaundice  is  usually  absent,  unless  some  secondary  disturbance 
has  been  induced.  The  child  emaciates  and  sinks  into  a 
state  of  collapse.  In  the  majority  of  the  cases  death  has 
taken  place  on  or  before  the  fifth  day. 

So  far  as  we  know  at  present,  no  treatm,cnt  is  of  any  avail. 


CONGENITAL    S  TRIG  TUBE.  235 

Of  all  operations  in  surgery  none  are  more  disastrous  than 
abdominal  sections  in  quite  young  infants.  So  far  as  my 
experience  goes,  these  operations  when  performed  within  a 
few  days  of  birth  only  hasten  death.  It  may  be  claimed 
that  they  hasten  it  mercifully.  It  will  be  apparent  from  the 
account  just  given  that  in  a  ver}^  large  proportion  of  the  cases 
the  defect  is  of  such  a  kind  that  it  could  only  be  remedied  by 
an  operation  of  great  length  and  great  complexity,  and  an 
infant  of  a  few  days  old  who  has  been  incessantly  vomiting  is 
not  a  subject  for  a  measure  of  this  kind. 

Cong-enital  Strictures  of  the  Jejunum  and  Ileum. — 
Congenital  defects  are  nuich  more  common  in  the  ileum 
than  in  the  jejunum.  In  the  ileum  they  are  most  usually 
discovered  in  that  segment  of  the  gut  with  which  the  vitelline 
duct  is  connected.  The  association  of  Meckel's  diverticulum 
mth  stricture  of  the  ileum  has  been  already  pointed  out 
(page  52).  In  not  a  few  of  the  recorded  cases  a  fibrous  band 
representing  the  remains  of  a  vitelline  duct  has  been  found 
attached  to  the  strictured  part  in  the  ileum,  but  as  a  rule 
the  contraction  is  unattended  by  any  such  relic. 

Whether  the  stenosis  be  situated  in  the  ileum  or  the 
jejunum,  the  appearances  which  may  be  presented  are  the 
same  in  the  two  sections  of  the  gut. 

The  bowel  may  be  occluded  by  a  complete  and  simple 
diaphragm  composed  of  the  mucous  and  circular  muscular 
coats.  This  may  be  associated  with  a  perfectly  normal 
appearance  of  the  bowel  externally,  or  with  a  little  constric- 
tion at  the  site  of  the  diaphragm.  The  diaphragm  may 
present  a  central  perforation  of  varying  dimensions.  In  the 
specimen  shown  in  Fig.  98  the  diameter  of  the  perforation 
was  a  quarter  of  an  inch.  The  part  involved  was  the  ileum, 
thirty-six  inches  from  the  csecum,  and  the  patient  was  a 
man  of  sixty-two,  who  had  exhibited  no  signs  of  intestinal 
embarrassment.^ 

The  stenosis  may  take  the  form  of  a  regular  contraction 
of  the  bowel,  which  may  narrow  the  lumen  of  the  gut  to  a 
mere  pin-hole,  or  may  obliterate  it  altogether.  The  bowel  at 
the  naiTowed  place  may  be  reduced  to  the  appearance  of 
a  solid  cord,  which  may  be  an  inch  or  more  in  length.  This 
cord  may  be  in  reality  solid  and  tibrous,  and  the  continuity 
of  the  intestine  be  entirely  destroyed.  On  the  other  hand, 
the  cord-like  section  may  be  sufficiently  pervious  to  allow 
the  intestinal  contents  to  pass.  Fig.  99  shows  this  last- 
named  condition.  The  specimen  was  taken  from  a  boy  of 
eight,  who  had  a  history  of  long-standing  abdominal  ilhiess, 

*  Hudson;  Path.  Soc.  Trans.,  Loud.,  1889,  p.  98. 


236 


STRICTURE    OF    THE    INTESTINE. 


-C 


and  who  died  of  perforative  peritonitis.  The  stricture  was  in 
the  ileum,  thirty-eight  inches  above  the  csecum.  The  gut  for 
three-quarters  of  an  inch  was  so  strictured  that  it  would 
barely  adroit  a  probe.  The  bowel  above  was  dilated  and 
greatlv  hypertrophied.  Five  polypi  were  found  in  the  bowel 
on  the  distal  side  of  the  stricture.^ 

Finally,  the  bowel  at  the  defective 
spot  may  be  entirely  obliterated,  and 
the  gut  above  and  the  gut  below  may 
end  each  in  a  cul-de-sac,  and  no  struc- 
tural connection  between  the  two  may 
be  discoverable. 

Congenital  strictures  of  the  small 
intestine  are  very  often  multiple.  I 
have  met  with  an  instance  in  which 
the  gut  was  'more  or  less  completely 
obliterated  in  six  places.  Certain  of 
the  sections  of  bowel  between  the  oc- 
cluded points  were  quite  isolated,  and 
looked  like  independent  closed  tubes. 
RoUeston  t  mentions  a  case  in  which 
three  diaphragmatic  obstructions  were 
n?u  the  Lower  discovered  in  the  body  of  a  man,  a^ed 
twenty-five,  who  had  presented  no  in- 
testinal troubles.  The  highest  of  these 
ext^af narrowing  Lf'^g.ftfo!  diaphragms  was  in  the  jejunum,  two 
diaphragm;  D,  mesentery.  feet  from  the  duodcnum.  Thc  apcrturs 
in  it  would  barely  admit  the  tip  of  the 
little  finger.  Turner  j  reports  a  curious  condition  found 
in  an  infant  who  died  of  intestinal  obstruction  four  days 
after  birth.  One  inch  of  the  middle  part  of  the  jejunum 
was  completely  isolated  and  shut  oft"  from  the  parts  above 
and  below  by  membranous  diaphragms.  The  occluded 
section  of  the  intestine  contained  a  little  mucus  only. 
Among  the  numerous  cases  which  have  been  recorded 
the  following  may  be  selected  as  presenting  points  of 
special  interest.  Mr.  W.  Thomas  §  gives  an  instance  in 
which  laparotomy  was  performed  for  complete  obstruction 
in  an  infant  five  days  old.  At  the  autopsy  the  jejunum 
was  found  to  end  in  a  blind  extremity  thirty-two  inches  from 
the  pylorus. 

In  another  instance  the  jejunum  a  few  inches  from  the 


Ftg.  98. 
Diaphragm  i 
Ileum  (JIi 
case.) 


*  Hudson;  Path.  Soc.  Trans.,  Lond.,  1889,  p.  99. 

t  Path.  Soc.  Trans.,  Lond.,  1891,  p.  122. 

t  Ibid.,  1887,  p.  14;j. 

§  £ri(.  Med.  Journ.,  Kov.  13,  1886. 


coxa  KNIT  A  L    S  TR  TO  TURE. 


2:57 


diiodenuiii  was  louiid  to  eiid  in  a  cid-de-sdc,  and  a  consider- 
able gap  existed  between  it  and  the  continuation  of  the  bowel. 
In  this  case  the  infant  hved  ten  days."^ 

In  a  case  reported  by  Mr.  E.  Willettt  Japarotomy  was 
performed  upon  an  infant  three 
days  old  for  obstruction,  which 
had  been  absolute  since  birth. 
The  child  died  in  ten  hours.  The  -■ 
intestine  was  entirely  occluded  at 
the  commencement  of  the  jejunum. 
The  greatly  dilated  duodenum  de- 
scended behind  the  peritoneuui 
and  behind  the  colon  into  the 
pelvis.  It  had  been  opened  in  the 
operation  which  had  been  carried 
out  in  the  right  iliac  region.  In 
another  example  mentioned  by 
Mr.  Willett  the  occlusion  was 
about  the  junction  of  the  jejunum 
and  ileum,  and  so  great  was  the 
distension  of  the  bowel  above  the 
obliterated  part  that  it  was  con- 
siderably larger  than  the  stomach. J 

Those  cases  of  stenosis  which 
are  found  in  the  lower  ileum  are  Fig.  99.— Congenital  stricture  of 
probably  dejjendent  upon  an  im- 
perfect or  too  thorough  oblitera- 
tion of  the  omphalo-mesenteric 
duct.  The  examples  of  occlusion 
elsewhere,  and  especially  the  multiple  strictures,  are  incapable 
at  present  of  satisfactory  explanation.  It  has  been  suggested 
that  the  diaphragms,  which  are  so  common,  are  due  to  faulty 
development  of  the  valvulte  conniventes,  but  the  explanation 
is  no  more  than  plausible. 

The  mj'sterious  affection  described  as  intra-uterine  peri- 
tonitis is  brought  forward  to  explain  these  congenital 
stenoses,  but,  as  a  matter  of  fact,  even  less  is  known  of 
the  peritonitis  than  of  the  strictures. 

The  symiJtoms  in  these  cases  will  vary  according  to  the 
de<?ree  of  the  obstruction.  From  the  instances  above  given 
it   will   be   seen   that   perfect    health    is    consistent   with    a 

*  Edin.  Med.  .Tcurn.,  1892,  p.  840. 

t  Path.  !Soc.  Trans.,  Lond..  1894,  p.  80. 

%  See  cases  reported  by  Therenuri  (Deut.  Zeits.  f.  Chir.  1877);  Holmes 
(Surgical  Diseases  of  Children,  p.  180);  Craig  [Edin.  Med.  Jour».,  vol.  xxvii., 
p.  146] ;  Davies-CoUey  (Path.  Soc.  Trans.,  vol.  xxix.,  p.  115);  and  Goodhart 
(ibid.,  vol.  xxxi.,  p.  Il4j. 


the  Ileum.  {Mr.  Hudson^ s  ease.) 

A,  proximal  end  of  bowel ;  b,  distal 
end  ;  c,  mesentery  ;  e,  dilated  gut 
containing  polypi. 


238  STRIGTUBE    OF    THE    INTESTINE. 

stricture  which  "vvould  barely  admit  the  tip  of  the  little 
finger,  and  that  life  ma}^  be  continued  for  many  years  with 
a  stricture  which  at  death  will  scarcely  admit  a  probe.  In 
the  examples  which  fall  short  of  complete  obliteration  the 
symptoms  are  those  of  stricture  of  the  small  intestine,  and 
the  treatment  is  identical  Avith  that  carried  out  in  that 
affection.  "With  regard  to  complete  obliteration  of  the  lumen 
of  the  bowel,  death  usually  takes  place  about  the  fifth  day, 
although  life  has  been  extended  for  double  that  period. 

The  remarks  which  have  been  made  respecting  the 
surgical  treatment  of  complete  congenital  obstruction  of 
the  duodenum  apply  also  to  this  condition.  Laparatomy 
has  been  many  times  performed,  but,  so  far  as  I  am  aware, 
it  has  been  in  every  instance  unsuccessful. 

Congenital  Stricture  of  the  Colon. — Congenital  stenoses 
of  the  colon  above  the  rectum  are  quite  rare.  As  already 
stated,  defects  in  the  development  of  the  rectal  segment  of  the 
bowel  are  the  most  common  of  the  congenital  troubles  met 
with  in  the  whole  alimentary  canal  The  entire  rectum 
may  be  absent.  Anderson  reports  a  case  in  which  an  infant 
passed  meconium  through  the  umbilicus.  It  lived  twenty- 
three  days,  and  at  the  autopsy  it  was  found  that  the  colon, 
which  was  otherwise  normal,  terminated  at  the  left  iliac 
crest  in  a  conical  cul-de-sac.'^  The  rectum  and  sigmoid 
flexure  were  quite  unrepresented. 

In  cases  in  which  the  rectum  is  entirely  absent  the 
colon  may  open  into  the  urethra  or  bladder.  Hurd  gives 
an  instance  in  which  a  child  lived  for  fifteen  months, 
passing  all  its  ftcces  per  urethram.f 

Hale  Whitej  refers  to  a  specimen  in  which  the  colon  was 
completely  occluded  by  a  membranous  septum  nine  inches 
above  the  anus. 

Dodd§  records  a  case  in  which  the  ascending  and  trans- 
verse colon  were  throughout  but  little  larger  than  an 
ordinary  lead  pencil.  The  infant  lived  twelve  weeks,  (ex- 
hibiting all  that  time  the  symptoms  of  intestinal  obstruction. 

Dr.  Hobson||  reported  the  following  case.  A  male  child — 
born  prematurely  at  seven  months — died  three  days  after 
birth,  having  presented  during  these  few  days  the  phenomena 
of  intestinal  obstruction.  The  examination  of  the  abdomen 
revealed  "  universal  adhesions  in  the  form  of  delicate,  easily- 
torn    bands.      The   whole    of    the  large   intestine    and    the 

*  Trans.  Path.  Soc,  Lond.,  1891,  p.  128. 

+  Boston  Med.  and  Surg.  Journ'.,  1885,  p.  294. 

X  Allbutt's  System  of  iledicine,  vol.  iii.,  p.  975. 

k  Lancet,  vol.  i.,  1892,  p.  1299. 

l]   Path.  Soc.  Trans.,  ISSo,  p.  217 


CONGENITAL    STRICTURE.  239 

small  intestine  for  about  sixteen  inches  above  the  otecum 
presented  the  appearance  of  a  solid  tube  averao^ing  about  one- 
fourth  of  an  inch  in  diameter,  pale,  and  stuffed  with  semi- 
solid matter.  Above  this  portion  the  intestine  suddenly 
expanded  to  a  size  which  would  be  above  the  normal  for 
so  young  an  infant."  At  a  point  in  the  narrowed  part  of 
the  intestine  a  break  in  the  continuity  of  the  gut  occurred. 
The  gap  measured  twelve  inches,  and  the  gut  above  and 
below  was  supported  by  the  same  fold  of  mesentery.  The 
specimen  is  in  the  museum  of  Guy's  Hospital. 

In  the  museum  of  the  London  Hospital  is  a  specimen 
(No.  1239)  in  which  the  colon  just  beyond  the  ileo-ca^cal 
valve  is  constricted.  Beyond  the  constriction  the  colon  is 
represented  by  a  blind  sac  one  inch  and  a  half  long.  The 
infant  from  whom  the  specimen  was  obtained  lived  four  days. 

The  symptoms  produced  in  these  cases  and  the  treatment 
adopted  call  for  no  particular  comment.  The  matter,  so  far 
as  the  terminal  part  of  the  colon  is  concerned,  is  fully 
discussed  in  the  many  works  which  deal  Avith  the  surgery 
of  the  rectum. 

The  subject  of  congenital  narrowing  of  the  sigmoid  flexure 
or  rectum  is  further  alluded  to  in  the  special  section  on  idiopathic 
dilatation  of  the  colon  (page  242).  It  is  there  attempted  to 
be  shown  that  certain,  at  least,  of  the  examples  of  idiopathic 
dilatation  of  the  colon  are  due  to  congenital  narrowing  of  the 
lower  part  of  the  large  intestine.  An  illustrative  case  is  given 
to  demonstrate  this  proposition. 

Other   Congenital   Malformations   of  the  Bowel. — 

The  majority  of  these  are  of  little  practical  interest.  There 
may  be  complete  transposition  of  the  viscera,  including  the 
intestine.  I  encountered  such  a  condition  once  when  removing 
an  ovarian  tumour. 

Very  considerable  segments  of  both  the  small  and  the 
large  intestine  may  be  absent,  the  condition  being  obviously 
inconsistent  with  life  and  utterly  irremediable. 

Mr.  Anderson^  reports  the  case  of  a  child  who  lived 
twenty-three  days  and  in  whom  there  was  an  absence  of 
both  sigmoid  flexure  and  rectum.  The  ileum,  however, 
opened  at  the  umbilicus,  forming  a  natural  artificial  anus. 

The  colon  may  be  provided  with  a  mesocolon  as  complete 
as  the  mesentery,  with  which  it  is  continuous.  The  caecum 
may  be  found  in  such  instances  free  within  the  abdominal 
cavity.  This  condition  plays  a  part  in  the  production  of 
certain  forms  of  volvulus.     (See  page  133.) 

*  Alluded  fo  on  p.  238. 


240  STBIGTUEE    OF    THE    IXTESTINE. 

The  csecuin  may  be  found  in  the  left  ihac  fossa,  or  near 
the  umbilicus,  or  inider  the  liver,  or  midway  between  the 
liver  and  the  right  iliac  fossa.  It  may  often  be  met  with  in 
the  pelvis.  In  a  case  reported,  by  Tirard^  the  caecum  was 
found  attached  by  a  distinct  omentum  to  the  fissure  for  the 
o-all  bladder,  the  gall  bladder  itself  lying  between  its  two  layers. 
The  colon,  starting  from  the  caecum,  passed  to  the  left  iliac 
fossa ;  it  then  made  a  sharp  bend  over  to  the  right  iliac  fossa, 
whence  it  passed  abruptly  into  the  pelvis  to  end  at  the  anus. 
In  a  case  described  by  Fowler t  the  cfecnm  was  found  to  be 
placed  behind  the  liver. 

Lockwoodj  gives  an  account  of  a  descending  colon  which 
vv^as  double. 

The  sigmoid  flexure  is  liable  to  great  variations  as  to 
length  and  position.  I  have  dealt  with  the  chief  of  these  in 
my  Hunterian  Lectures  on  the  "  Anatom}^  of  the  Intestinal 
Canal  and  Peritoneum  in  Man  "  (London,  1885). 

An  interesting  account  of  certain  variations  in  this  part 
of  the  bowel  is  given  by  Melsome  in  the  Proceedings  of  the 
Anatomical  Society  of  Great  Britain.  § 

The  condition  of  the  sigmoid  flexure  which  predisposes  to 
volvulus  is  described  in  the  chapter  on  that  form  of  intestinal 
obstruction  (page  127). 

A  quite  remarkable  case  of  congenital  malposition  of  the 
colon  is  described  by  Dr.  Florence  Boyd.||  The  patient  was 
a  woman,  aged  thirty-nine,  who  had  suffered  from  a  severe 
degree  of  indigestion  for  six  years. 

While  under  treatment  in  the  New  Hospital  for  AVomen 
she  was  seized  with  abdominal  pain  attended  with  great 
distension  of  the  belly,  and  later  with  vomiting,  which, 
however,  never  became  a  distressing  symptom.  The  disten- 
sion was  most  marked  in  the  csecal  region.  The  bowels 
acted  irregularly  and  with  difficulty.  Before  the  onset 
of  this  attack  there  had  been  periods  of  distension  of 
the  abdomen,  associated  with  marked  tenderness  in 
the  epigastrium  and  visible  movements  of  the  dilated 
colon. 

Laparotomy  was  performed  on  the  eleventh  day,  but  the 
patient  died  in  thirty-six  hours.  A  mass  which  had  been 
felt  in  the  abdomen  before  the  operation  proved  to  be  made 
up  of  much  thickened  mesentery  containing  some  enlarged 
glands.     A  little  small  intestine  was  found  to  be  compressed 

*  lancet,  vol.  ii.,  1892,  p.  1131. 

t  Annals  of  Surgery,  1894,  p.  160. 

X  Brit.  Med.  Jomn.,  1882,  vol.  ii.,  p.  574. 

§  Joiirn.  of  Ana t.  and  Phya.,  1892-3,  p.  xxx. 

I|  Lancet,  July  3,  1897. 


CONGENITA  L    MALFOBMA  TIONS. 


241 


beneath  the  tightly-drawn  mesentery.     This  was  released,  but 
without  relief  to  the  symptoms. 

The  post-mortem  examination  was  made  thirty-six  hours 
after  death.  On  opening'  the  abdomen,  the  most  prominent 
objects  were  the  much-distended  csecum  and  the  ascending 
colon,  extending  from  the  pelvis  along  the  right  side  of  the 
abdomen  (Fig.  100).  Towards  the  left,  part  of  the  transverse 
colon  was  seen,  and  nothing  else  was  visible  but  coils  of 
small  intestine,  some  being  deeply  congested.  The  c?ecum 
could  be  lifted  out  of  the  pelvis,  and  was  quite  free,  being, 
as  well  as  most  of  the  ascending  colon,  surrounded  entirely 
by  peritoneum.  The  free  caecum,  ascending  colon,  and  the 
greater  part  of  the  small  intestine  had  made  a  complete 
revolution  from  left  to  right,  and  from  behind  forwards. 
Continuous  with  the  lower  and  left  edge  of  the  mesentery 
was  a  short,  well-marked  ascending  mesocolon.  The  stomach 
was  of  an  hour-glass  shape,  and  extended  far  down  into  the 
abdomen.  On  following  it 
down,  the  pyloric  end  was 
found  to  pass  downwards  in 
front  of,  then  upwards  and  be- 
hind, the  right  end  of  the 
transverse  colon  (Fig.  101),  the 
two  viscera  thus  constricting 
one   another.     The  duodenum 

examined ;       the 

third   parts   bore 

relations  to  the 
right  kidney  and  pancreas,  but 
the  first  part,  owing  to  the 
faulty  position  of  the  pylorus, 
was  too  long,  and  ascended 
vertically  in  front  of  the  second 
part  (Fig.  101).  The  jejunum 
turned  as  usual  sharply  for- 
wards and  to  the  right.  The 
mesentery  appeared  at  the 
upper  border  of  the  right  end 
of  the  transverse  colon  in  front 
of  the  junction  of  the  stomach 
and  duodenum  (Fig.  101),  and 
to   the   outer  or  right  side  of 

the  colon.  The  small  intestine  was  now  removed.  For 
twelve  feet  of  its  extent  it  was  not  injected ;  the  re- 
mainder was  of  a  purple  colour,  and  the  mesentery  of 
this  part  (the  part  involved  with  the  caecum  in  the 
Q 


was      next 
second   and 
the    normal 


Fig.  100. — Mrs.  Boyd's  case  of  Cou- 
genital  Deformity  of  the  Colon. 

View  on  oiieniug  the  abdomen  : — l,  liver  ; 
s  G,  small  gut ;  c,  caecum  ;  t  c,  transverse 
colon  ;  SF,  splenic  flexure. 


242 


S  TRIG  TUBE    OF    THE    INTESTINE. 


volvulus)  was  tliickened  and  contained  swollen  glands, 
which  formed  the  firm  mass  felt.  There  was  a  constriction 
just  beyond  the  dilated  hepatic  flexure  of  the  colon  (Fig.  101). 
The  transverse  colon  here  passed  in  front  of  the  vertically 
placed  pyloric  end  of  the  stomach,  and  then  from  above 
down  behind  the  stomach  to  gain  its  normal  position  with 

regard  to  the  greater  curva- 
ture. As  the  colon  thus 
hooked  round  the  stomach 
its  calibre  was  diminished, 
and  this  was  the  cause  of 
the  chronic  obstruction. 

Regarding  the  case  gener- 
ally, it  would  appear  that  at 
least  two  distinct  conditions 


were  present,  viz.  an  inter- 
locking of  the  transverse 
colon  and  the  stomach  and 
a  volvulus  of  the  caecum 
and  lower  part  of  the  small 
intestine. 

The  former  position  is  ex- 
plained by  Dr.  Boyd  by  "an 
abnormal  intertwining  of  the 
stomach  and  the  primary  in- 
testinal fold  at  a  very  early 
period  of  development." 

The  latter  condition  re- 
presents a  form  of  volvulus 
which  is  rendered  possible 
when  the  colon  on  the  right 
side  is  free  and  has  a  liberal 
mesocolon. 

the 


Fio.  101. — Mrs.  Boyd's  case  of  Con- 
genital Deformity  of  the  Colon. 

View  after  removal  of  small  intestine  : — 
L,  liver;  o  b,  gall  bladder  ;  s,  stomach  ; 
Dj,  Do,  D:j,  Ist,  2nd  and  3i-d  parts  of  duo- 
denum ;  c,  caecum  ;  ac,  tc,  dc,  ascend- 
ing, transverse  and  descending  colon  ; 
s  F,  splenix  flexure ;  p,  pancreas  ;  m, 
mesentery. 


The   specimen    is   in 
museum  of  the  Royal  College  of  Surgeons. 


IDIOPATHIC   DILATATION   OF   THE   COLON. 

01  late  years  there  has  crept  into  medicine  the  term 
"idiopathic  dilatation  of  the  colon."  This  term  has  been 
applied  to  certain  morbid  conditions  in  which  a  few  common 
clinical  manifestations  appear  to  have  given  expression  to 
varied  and  possibly  diverse  pathological  states.  Whatever 
may  be  the  structural  changes  which  give  rise  to  this  dila- 
tation of  the  bowel,  the  clinical  phenomena  included  under 
the  term  are  more  or  less  definite  and  unvaried.     The  main 


IDIOPATHIC    DILATATION    OF    THE    COLON.         243 

features  are  these.  The  colon,  and  especially  the  lower  part 
of  it,  is  enormously  dilated.  It  is  tympanitic  and  distended 
Avith  gas  to  a  degree  that  in  some  instances  almost  surpasses 
belief.  The  patient  suffers  from  certain  mechanical  effects 
of  this  distension,  and  notably  from  shortness  of  breath, 
palpitation  of  the  heart,  oedema  of  the  legs,  and  possibly 
albuminuria.  The  patient  may  be  unable  to  move,  and  the 
difficulty  of  breathing  may  be  such  that  the  face  and 
extremities  become  livid.  Marked  constipation  is  usually  a 
conspicuous  feature,  while  vomiting  and  troublesome  hiccough 
are  not  uncommon.  The  particular  term  "  idiopathic  dilata- 
tion "  is  based  upon  the  assumption  that  the  distension  of 
the  bowel  is  not  due  to  any  obstruction  in  its  lumen.  It  is 
therefore  necessary  to  exclude  from  the  present  category  all 
cases  of  dilatation  of  the  colon  due  to  volvulus,  to  the 
impaction  of  fsecal  masses  or  foreign  bodies,  to  the  lodgment 
of  concretions,  and  to  the  existence  of  stricture  of  any 
type.  In  like  manner  would  be  excluded  examples  in  which 
the  colon  or  rectum  has  been  narrowed  or  occluded  by 
the  pressure  of  a  tumour  having  its  origin  without  the 
bowel  wall. 

In  dealing  with  this  present  subject,  it  will  be  well  to 
inquire,  first  of  all,  into  the  circumstances  in  which  portions 
of  the  alimentary  canal  become  dilated  in  the  absence  of  any 
obstructive  cause,  and,  in  the  second  place,  to  consider  what 
conditions  may  underlie  certain  of  the  reported  cases  of 
"  idiopathic  dilatation  of  the  colon."  With  regard  to  the  first 
matter,  it  may  be  said  at  once  that  any  part  of  the  alimentary 
tube  may  become  dilated  without  there  being  the  least 
obstruction  in  its  lumen.  At  one  time  it  was  supposed  that 
whenever  the  stomach  was  dilated  there  was  some  obstruction 
at  the  pylorus  which  prevented  the  escape  of  the  gastric 
contents  and  allowed  the  organ  to  be  dilated  by  the  gaseous 
products  of  decomposition.  In  like  manner,  in  marked  tym- 
panites of  the  bowel  it  was  loosely  assumed  that  the  bowel  was 
distended  with  gas,  which  could  not  escape  owing  to  some 
obstruction  in  the  distal  part  of  the  canal.  These  assumptions 
have  long  since  been  shown  to  be  without  foundation. 
Obstruction  in  the  lumen  of  the  intestine  is  not  the  most 
ready  means  of  inducing  meteorism.  Interference  with  the 
innervation  and  blood-supply  of  the  gut  will  cause  a  much 
more  speedy  tympanites  (page  13).  In  animals,  the  ligaturing 
of  the  main  mesenteric  vein  is  followed  by  quite  intense 
meteorism ;  and  one  of  the  most  extreme  examples  I  have 
seen  of  tympanites  of  the  small  intestine  in  the  human  subject 
was  due  to  thrombosis  of  the  superior  mesenteric  vein. 


'2W  ■   STEiriTURE    OF    THE    INTESTINE. 

From  a  clinical  point  of  view,  it  is  desirable  to  recognise 
most  full}"  that  distension  of  any  portion  of  the  alimentary 
canal  may  be  entirely  dissociated  from  any  obstruction  in 
the  lumen  of  the  tube.  Certain  phases  of  "  idiopathic  dilata- 
tion "  immediately  suggest  themselves.  One  of  the  most 
interesting  is  provided  by  the  condition  known  as  "  ballooning 
of  the  rectum."  Here,  on  introducing  the  tinger  into  the 
anus,  the  rectum  is  found  to  be  apparently  dilated  to  its 
utmost.  It  may  be  dilated  in  the  same  way  as  one  speaks  of 
the  iris  as  dilated,  but  it  is  certainly  not  distended ;  and  the 
term  "  ballooning,"  which  suggests  extreme  inflation  with  gas, 
is  entirely  misleading.  The  ballooned  rectum  is  not  distended 
with  gas,  but  its  condition  is  due  to  some  phase  of  paralysis. 
If  two  fingers  be  introduced  into  such  a  rectum  so  to  allow 
gas  to  escape,  the  ballooning  remains  the  same.  It  is  the 
muscular  wall  of  the  gut  Avhich  is  at  fault  and  not  its 
contents.  On  the  other  hand,  if  the  patient  be  anaesthetised 
the  ballooning  vanishes.  This  ballooninsf  is  met  with  in 
many  conditions.  It  is  often  associated  with  stricture  of  the 
lower  colon,  with  tumours  about  the  pelvic  brim,  with  condi- 
tions indeed  which  may,  through  pressure,  affect  the  innerva- 
tion and  blood-supply  of  the  terminal  part  of  the  gut.  I  have 
met  with  a  very  marked  example  of  "  ballooning  "  in  an  old 
man,  who  was  suffering  from  what  proved  to  be  a  fatal  attack 
of  subacute  perityphlitis.  Those  who  are  concerned  with  the 
physiology  of  idiopathic  dilatation  of  the  bowel  may  well 
commence  with  the  study  of  ballooning  of  the  rectum. 

Idiopathic  dilatation  of  the  colon  of  moderate  degTee  is 
v/ell  seen  in  what  may  be  termed  masked  peritonitis.  Indeed, 
a  little  inflammatory  focus  within  the  abdomen  (and  without 
the  pelvis)  is  a  common  cause  of  persisting  dilatation  of  bowel. 
As  an  example  of  masked  peritonitis,  I  may  take  such  a  case 
as  the  following.  An  abdominal  section — such  as  the  removing 
of  a  diseased  vermiform  appendix — is  performed.  For  a  day 
or  two  all  goes  well,  and  then  appear  the  phenomena  of 
masked  peritonitis.  There  is  great  distension  of  the  epigastric 
region  due  apparently  to  dilatation  of  the  transverse  colon. 
The  patient  is  very  frequently  sick  and  can  retain  little  or 
nothing  in  the  stomach.  He  has  obstinate  and  often  most 
persistent  hiccough.  There  is  no  pain  or  next  to  none,  no 
tenderness  of  the  abdomen,  and  no  board-like  hardness  of  the 
abdominal  muscles.  The  abdomen  ma}^  be  perfectly  soft  in 
all  parts,  there  is  no  rise  of  temperature,  the  bowels  respond 
to  enemata  and  to  such  an  aperient  as  calomel ;  but  the 
dilatation  of  the  colon,  the  irritability  of  the  stomach,  and 
possibly  the  hiccough  persist.     After  the  bowels  have  acted, 


iniOFATHIG    DILATATION    OF    THE    COLON.  245 

there  is  some  little  diminution  in  the  epigastric  distension  ; 
but  it  is  only  temporary.  The  symptoms  may  last  for  many 
anxious  days  and  at  last  end  in  recovery.  It  may  be  men- 
tioned that  in  this  condition  no  drug  answers  so  well  as 
strychnia  administered  hypodermically. 

As  regards  the  stomach,  it  is  needless  to  say  that  certain 
forms  of  dilatation  of  that  organ  are  described  in  which  there 
is  no  evidence  of  any  obstruction  of  the  pylorus.  There  is 
a  good  deal  to  suggest  that  some  forms  of  rapid  dilatation 
of  the  stomach  may  depend  upon  nerve  influences  which 
have  their  starting-point  in  some  infective  or  inflammatory 
process.  In  one  of  the  two  fatal  cases  of  "  acute  gastric 
distension "  described  by  Dr.  Fagge,  a  sloughing  abscess  was 
discovered  behind  the  duodenum  after  death.  Acute  dilata- 
tion of  the  stomach  of  the  ordinary  type  is  said  by  Dr.  Clif- 
ford Allbutt  only  to  occur  as  the  sequel  of  certain  acute 
and  debilitating  diseases  such  as  acute  rheumatism,  active 
forms  of  pulmonary  tuberculosis,  malignant  endocarditis,  and 
septicaemia.  I  have  seen  acute  dilatation  of  the  stomach 
follow  upon  severe  and  extensive  contusion  of  the  abdomen 
from  which  the  patient  ultimately  recovered  and  in  which 
there  was  no  evidence  that  there  was  at  any  time  an  obstruc- 
tion of  the  pylorus. 

So  far,  then,  it  may  be  safe  to  say  that  in  certain 
portions  of  the  alimentary  canal  extensive  dilatation  may 
occur  which  is  independent  of  any  obstruction  in  the 
lumen  of  the  tube.  To  such  forms  the  somewhat  vague 
term  "  idiopathic "  may,  with  a  scarcely  less  vague  reason, 
be  ascribed. 

When  we  turn  to  the  series  of  clinical  cases  which  are 
collected  under  the  title  of  "idiopathic  dilatation  of  the 
colon,"  it  is  evident  that  we  have  to  deal  with  conditions 
which  are  much  less  ephemeral  than  the  casual  states  of 
distension  to  which  allusion  has  just  been  made.  An 
examination  of  this  collection  of  cases  at  once  raises  the 
question  as  to  how  far  they  are  accurately  described  by  the 
term  "idiopathic."  Certain  of  the  reported  examples  are, 
as  Dr.  Hale  White ^  has  pointed  out,  apparently  instances 
of  extreme  faecal  accumulation.  In  a  case  under  the  care 
of  Dr.  Bristowe,t  for  example,  the  patient,  a  girl  aged  eight 
years,  had  had  no  action  of  the  bowels  for  seven  weeks  before 
her  admission  into  hospital.  She  had  always  been  the  subject 
of  constipation,  and  at  her  death  the  entire  colon  Avas  found 
to  be  enormously  distended  with  feeces  to  a  point  within  two 

*  Clifford  AUbutt's  System  of  Medicine,  vol.  iii.,  p.  968. 
"I"  Brit.  Med.  Joiirn.,  vol.  i.,  1885,  p.  1085. 


246  STBIGTUllE    OF    THE    INTESTINE. 

inches  of  the  anus.  In  another  case  ^  selected  by  Dr.  Hale 
White  the  patient  was  a  man,  aged  twenty-eight  years,  who 
had  been  always  constipated  and  who  had  had  several  attacks 
due  to  fsecal  accumulation.  The  distension  of  his  abdomen 
Avas  enormous,  and  there  was  oedema  of  the  legs,  penis,  and 
scrotum.  The  colon  had  a  diameter  of  from  six  to  eight 
inches,  and  contained  no  less  than  fifteen  quarts  of  fsecal 
matter. 

When  the  other  cases  come  to  be  examined,  it  is  at  once 
evident  that  they  can  be  divided  into  two  classes.  In  one 
series  of  cases  the  patients  are  adults,  are  mostly  males,  and 
are  over  fifty  years  of  age.  In  the  other  series  of  cases  the 
patients  are  children,  and  symptoms  of  abdominal  trouble 
have  been  more  or  less  apparent  from  birth. 

These  two  classes  of  cases  must  be  dealt  with  separately. 

1.  The  Cases  in  Adults. — As  an  illustration  of  a  case 
coming  under  this  heading  the  following  may  be  selected. 
It  will  be  observed  that  it  conforms  to  the  description  above 
given. 

Mr.  Berry  t  reports  the  case  of  a  man,  aged  seventy- 
three,  who  was  admitted  into  St.  Bartholomew's  Hospital  in 
a  dying  condition. 

"  For  many  years  he  had  been  subject  to  chronic  constipation. 
Three  years  before  his  death  an  attack  of  intestinal  obstruction  had 
yiekled  to  a  smart  purge,  and  from  that  time  his  bowels  had  given  him 
little  trouble  until  nine  days  before  his  admission.  Since  that  time 
there  had  been  no  action  of  the  bowels.  Vomiting  had  begun  on  the 
day  before  admission  ;  on  admission  he  was  in  a  state  of  collapse.  _  An 
exploratory  laparotomy  showed  that  the  peritoneal  cavity  contained 
free  gas  and  fjeces,  and  a  large  rent  was  found  in  the  sigmoid  flexure. 
Death  occurred  a  few  hours  later.  At  the  post-mortem  the  csecum  and 
the  whole  of  the  colon  down  to  the  sigmoid  flexure  were  found  to  be 
unaffected  and  not  distended.  The  rectum  was  quite  natural,  no 
stricture  of  any  kind  being  found  in  it.  The  sigmoid  flexure,  however, 
was  enormously  distended,  resembling  in  shape  and  size  an  inverted 
and  d.istended  stomach.  It  extended  upwards  into  the  left  hypochon- 
driac and  epigastric  regions,  and  was  attached  by  old  adhesions  to  the 
liver  and  spleen  Its  wall  was  much  thickened,  evidently  by  hyper- 
trophy ;  the  inner  surface  showed  several  shallow  ulcers  ;  in  several 
places  the  wall  was  gangrenous  and  perforated.  The  two  ends  of  the 
sigmoid  flexure  were  normal  in  size  and  position.  The  rectum  was  not 
involved  in  the  distension,  and  nowhere  was  there  any  trace  of  stricture 
or  other  cause  of  obstruction." 

Another  case,  with  somewhat  different  features,  is  one 
recorded  by  Dr.  Money  and  Mr.  S.  Paget. J 

*  Dr.  Peacock's  case  ;  Transactions  of  the  Pathological  Society  of  London, 
vol.  xxxiii. 

t  Path.  Soc.  Trans.,  Lond.,  1894,  p.  84. 
+  Clin.  Soc.  Trans.,  Lond.,  1888,  p.  103 


IDIOPATHIC    DILATATION    OF    THE    COLON.  247 

The  patient  was  a  man  of  tit'ty-three,  a  confirmed 
cirimkard.  For  some  months  before  his  death  distension 
of  the  abdomen  had  made  its  appearance,  and  had 
steadily  increased.  When  seen  shortly  before  his  death, 
the  abdomen  was  enormous,  and  had  a  circumference  of 
no  less  than  five  feet.  It  was  everywhere  resonant,  and 
free  from  pain  and  tenderness.  He  had  oedema  of  the 
leofs  and  albumen  in  the  urine.  His  breathino-  was 
embarrassed.  His  bowels  had  always  acted  regularly, 
although  they  were  somewhat  constipated  some  few 
weeks  before  his  death.  He  was  for  a  time  relieved  by 
puncturing  the  abdomen,  but  he  died  finally  from  exhaus- 
tion following  delirium  tremens,  complicated  by  extensive 
bronchitis.  The  dilatation  was  limited  to  the  colon  and 
practically  to  the  sigmoid  flexure.  This  portion  of  the  bowel 
presented  the  appearance  of  two  large  sacs,  each  far  bigger 
than  any  ordinary  dilated  stomach.  These  sacs  and  the 
rest  of  the  colon  contained  much  gas,  and  much  faecal 
matter  of  the  consistence  of  ordinary  gruel.  There  was 
considerable  hypertrophy  of  the  walls  of  the  dilated 
colon.  No  mechanical  obstruction  of  any  kind  was 
discoverable  in  the  bowel  below  the  distended  section. 
There  was  cirrhosis  of  the  liver.  The  kidneys  were 
granular.  The  disposition  for  the  dilated  sigmoid  loop 
to  become  folded  upon  itself  so  as  to  present  an  appear- 
ance as  of  two  sacs  is  not  uncommon.  Dr.  Gee  ^  reports 
a  case  of  distension  of  this  part  of  the  colon,  in  which  the 
bowel  presented  as  two  huge  sacs  placed  vertically  side  by 
side,  and  occupying  the  whole  of  the  front  of  the  abdomen. 

In  an  example  of  "  idiopathic  dilatation  of  the  colon," 
described  by  Dr.  Herringham  and  Mr.  Bruce  Clarke  f  the 
patient,  a  man  of  seventy-eight,  is  described  as  being  of  a 
very  constipated  habit,  but  "  for  the  last  six  months  he 
had  had  little  or  no  trouble  ;  the  bowels  had  been  opened 
regularly   without  more  than  an  occasional    mild  aperient." 

His  death,  which  was  due  to  perforation  of  the  distended 
sigmoid  flexure,  was  preceded  by  absolute  constipation  extend- 
ing over  eight  days. 

From  the  consideration  of  the  other  reported  examples  of 
this  affection  it  would  appear  that  it  is  much  more  common 
in  men  than  in  women,  and  is  most  apt  to  be  met  with  alter 
middle  life.  There  may  or  may  not  be  a  history  of  constipa- 
tion, or  a  history  of  actual  fgecal  obstruction.  The  dilatation 
of  the  colon  is  of  slow  development,  and  in  time  becomes 

*  St.  Bart's.  Hosp.  Reports,  vol.  xx.,  p.  19. 
t  £rii.  Med.Journ.,  189i,  vol.  ii.,  p.  1240. 


248  STBICTURE    OF    THE    INTESTINE. 

quite  excessive.  Examination  sliows  that  gas  is  the  chief 
cause  of  the  distension.  The  dilated  bowel  becomes  hyper- 
trophied.  The  enlargement  of  the  colon  may  be  such  as 
to  cause  alarming  palpitation  and  shortness  of  breath,  and 
pressure  upon  the  iliac  veins  may  lead  to  oedema  of  the 
scrotum  and  lower  limbs. 

The  dilated  colon  is  apt  to  become  the  seat  of  catarrh, 
and  its  mucous  membrane  to  be  ulcerated.  Now  and  then 
diarrhoea  has  set  in  before  death 

Some  patients,  as  in  Money's  case,  have  died  from  causes 
not  directly  and  solely  due  to  the  condition  of  the  bowel,  but 
the  majority  have  succumbed  to  perforation  of  the  gigantic 
coil. 

The  pathology  of  this  affection  can  as  yet  only  be  dealt 
with  in  a  speculative  manner. 

The  so-called  sigmoid  flexure  forms,  as  is  well  known,  a 
large  loop,  which  conforms  very  closely  to  the  outlines  of  a 
capital  omega. 

In  certain  subjects  of  chronic  constipation  the  loop  is 
found  elongated  and  the  two  extremities  of  the  omega  are 
brought  very  close  together.  Through  the  narrow  strait 
bounded  by  these  two  extremities  of  the  bowel  the  vessels 
and  nerves  of  the  loop  pass. 

The  loop,  if  at  all  loaded,  is  very  apt  to  hang  down  into 
the  pelvis.  If  unequally  loaded,  it  is  not  difficult  to  see 
that  it  may  become  a  little  twisted  on  itself,  and  the  effect 
of  such  twisting,  trifling  as  it  may  be,  would  concern  most 
directly  the  root  of  the  loop,  the  spot  at  which  the  vessels 
and  nerves  were  entering.  It  would  require  no  very  aggres- 
sive interference  with  these  structures  in  the  narrow  strait 
of  the  sigmoid  mesocolon  to  produce  marked  effect  upon 
the  bowel.  Pressure  upon  the  veins  returning  from  the 
loop  would  tend  to  produce  some  slight  engorgement,  and 
following  upon  that  some  meteorism.  In  another  chapter 
of  this  work  attention  is  drawn  to  the  part  played  by  the 
circulation  in  the  production  of  meteorism  (page  13),  and  in 
the  cases  now  under  consideration  the  enormous  distension 
to  which  the  bowel  is  subject  is  found  to  be  mainly  due 
to  gas.  Disturbances  about  the  root  of  the  loop  would  be 
apt  also  to  affect  the  nerves  entering  the  bowel,  and  it  would 
seem  as  if  the  sigmoid  flexure  were  peculiarly  susceptible 
to  nervous  influences.  It  is  a  part  of  the  intestine  easily 
examined  through  the  parietes,  and  in  certain  irritative 
conditions,  such  as  colitis,  it  stands  out  with  remarkable 
distinctness  as  a  contracted  tube. 

I  have  been  able  to  feel  more  than  a  foot  of  it,  presenting 


IDIOPATHIC    DILATATION    OF    THE    COLON.  240 

to  the  touch  ahnost  the  impression  of  a  solid  rope.  In  cases 
of  stricture  of  the  rectum  the  contraction  or  dilatation  of 
the  omega  loop  often  becomes  very  apparent,  and  its  irrita- 
bility conspicuous. 

It  has  been  suggested  by  more  than  one  writer  that  the 
affection  now  under  consideration  is  comparable  to  those 
states  of  dilatation  of  the  stomach  which  are  not  associated 
with  any  mechanical  obstruction  at  or  about  the  pylorus. 
It  is  the  opinion  of  many  that  these  forms  of  the  dilated 
stomach  are  commonly  due  to  catarrh,  and  there  are  circum- 
stances in  connection  with  the  reported  cases  of  idiopathic 
dilatation  of  the  colon  which  render  the  existence  of  a 
previous  catarrh  of  the  bowel  very  probable. 

The  marked  hypertrophy  of  the  wall  of  the  distended 
colon,  however,  is  difficult  to  interpret.  It  strongly  suggests 
an  obstacle  in  the  bowel  just  beyond  the  dilated  part 
Avhich  the  muscular  coat  of  the  gut  has  been  struggling  to 
overcome. 

It  may  be  that  a  frequently  overloaded  omega  loop  can 
become  so  twisted  upon  itself  as  to  produce  some  obstruction 
in  its  lumen  without  at  the  same  time  causing  any  acute 
symptoms. 

Those  patients — among  the  present  series — who  have  been 
the  subjects  of  long-abiding  constipation,  and  who  have  had 
"definite  obstructive  attacks,  may  very  probably  illustrate  this 
method  of  causation. 

I  think  that  the  future  will  show  that  a  careful  exami- 
nation of  cases  post-mortem  will  reveal  some  mechanical 
obstruction  in  the  tube,  and  that  the  evidence  that  the 
dilatation  is  idiopathic  will  become  less  and  less  convincing. 
The  following  case  is  probably  more  to  be  regarded  as  a  type 
than  those  which  have  been  already  described.  It  is  reported 
by  Dr.  Hichens."^ 

The  patient  was  a  young  man  aged  twenty  years.  From  the  day  of 
his  birth  to  the  day  of  his  death  he  suffered  from  constipation,  and  liis 
bowels  were  apparently  never  opened  without  recourse  to  artificial 
means.  For  tlie  first  week;  of  his  life  he  was  exceedingly  ill,  passed 
nothing  but  blood  and  "water"  by  the  rectum,  and  A\as  not  expected  to 
live.  After  the  first  week  he  laegan  ])assing  ftecal  matter,  but  the 
motions  were  never  those  proper  to  an  infant,  consisting  almost  entirely 
of  scybala,  and  they  were  passed  with  much  pain  and  screaming.  The 
motions,  such  as  they  were,  were  not  obtained  Avitliout  jircvious  half- 
ounce  doses  of  castor  oil,  which  olten  had  to  be  repeated  two  oi-  three 
times  in  the  course  of  twelve  hours  before  the  bowels  acted.  As  the 
child  grew  the  bowels  were  only  opened  by  drugs,  and  with  increased 
difficulty,  and  at  the  age  of  twelve  months  the  mother  began  to  have 
recourse  to  half-pint  enemas  of  soap  and  water.  Later  enemas  of  a 
*  lancet,  Oct.  29,  1898. 


250  STRICTURE    OF    THE    INTESTINE. 

whole  pint  had  to  be  given,  and  very  often  had  to  be  repeated  two  or 
three  times  before  the  bowels  were  opened.  The  after-history  of  the 
case  is  merely  a  repetition.  The  bowels  used  only  to  be  opened  at 
intervals  of  ten  days  or  a  fortnight,  and  only  after  repeated  enemas. 
A  very  large  scybalous  motion  was  then  passed,  generally  succeeded  by 
several  loose  motions,  spread  over  the  next  two  or  three  days.  The 
patient  very  often  felt  slightly  sick  before  the  bowels  were  opened  and 
was  very  much  collapsed  afterwards,  so  much  so  that  he  often  had  to 
go  to  bed  for  the  rest  of  the  day.  His  abdomen  was  always  greatly 
distended,  so  that  he  could  never  button  the  bottom  button  of  his 
Avaistcoat  or  the  top  button  of  his  trousers.  Five  days  before  death  he 
was  seized  with  pains  all  over  his  body  and  slight  swelling  of  the  legs, 
and  in  consequence  he  hurried  home.  He  was  treated  by  a  medical 
man  who  thought  that  he  had  rheumatic  fever.  The  night  before  he 
died  he  passed  a  fairly  large  motion.  On  the  morning  of  the  next  day 
he  was  seized  with  a  severe  pain  over  the  heart  for  which  the  preecordial 
area  was  rubbed  with  liniment,  which  gave  him  considerable  relief,  and 
shortly  afterwards  he  went  to  bed  feeling  fairly  comfortable.  During 
the  following  night  he  suddenly  got  out  of  bed  for  some  unknown 
reason  and  fell  down  dead. 

At  the  necropsy  there  was  enormous  general  distension  of  the 
abdomen.  On  reflecting  the  parietes,  the  abdominal  cavity  was  found 
to  be  occupied  by  a  tense  shining  viscus,  presenting  the  appearance  of 
a  sac  rising  out  of  the  pelvis  and  passing  under  the  ribs,  where  it 
doubled  on  itself  and  returned  to  the  pelvis  again.  On  closer  inspec- 
tion, this  jjroved  to  be  an  enormously  distended  sigmoid  flexure.  Some 
little  distance  above  the  junction  with  the  rectum  the  viscus  showed  a 
distinct  constriction.  The  remaining  abdominal  viscera  were  entirely 
concealed  by  the  sigmoid  flexure,  which  pushed  the  liver  upwards  and 
backwards,  compressed  the  lungs,  and  rotated  the  heart  upwards  and 
outwards.  On  removing  the  sigmoid  flexure  and  laying  it  open,  it  was 
found  to  contain  an  enormous  amount  of  gas,  and  also  a  large  quantity 
of  semi-liquid  fseces  of  the  consistence  of  pea-soup.  The  total  length 
of  the  sigmoid  flexui'e  when  it  was  opened  and  laid  flat  was  twenty-two 
and  a  half  inches.  Fourteen  inches  from  its  upper  end  was  a  large 
cicatrix  formed  by  an  almost  healed  ulcer,  probably  stercoral  in  origin, 
which  had  caused  the  constriction  above  mentioned.  The  circumfer- 
ence of  the  flexure  above  the  ulcer  w^as  fourteen  inches,  at  the  ulcer 
it  was  seven  and  three-quarters  inches,  and  below  the  ulcer  it  was  ten 
inches.  The  wall  of  the  bowel  was  greatly  hypertrophied.  There  was 
a  little  rotation  of  the  bowel  upon  itself. 

2.  The  Cases  in  Children. — With  regard  to  the  cases  of 
"  idiopathic  dilatation  of  the  colon  "  in  children,  it  appears 
to  me  that  they  have  even  less  claim  to  the  title  "idio- 
pathic" than  have  the  instances  just  disposed  of. 

The  evidence  obtained  from  the  perusal  of  these  cases  very 
strongly  suggests  that  the  great  majority  of  them  at  least 
depend  upon  a  congenital  narrowing  of  the  lower  extremity 
of  the  large  intestine.  Later  (page  254  et  seqq.)  I  have  given 
an  account  of  a  small  child  who  exhibited  in  a  marked  degree 
the  features  of  "  idiopathic  dilatation  of  the  colon,"  as  shown 
by  the  enormous  distension  of  the  abdomen,  the  obstinate 
constipation,  the  hypertrophy  of  the  lower  part  of  the  colon, 


WIOPATEIC    DILATATION    OF    THE    COLON.         251 

and  the  practical  failure  of  all  purgative  measures.  The  case, 
indeed,  may  be  taken  as  a  quite  typical  example  of  the  trouble 
described  under  this  questionable  title.  The  patient  was 
treated  by  operation,  and  the  whole  of  the  bowel  below  the 
transverse  colon  removed  together  with  the  anus.  The  child 
made  an  easy  recovery.  The  examination  of  the  bowel,  how- 
ever, made  it  evident  that  the  distension  was  not  "  idiopathic," 
but  was  due  to  a  congenital  naiTowino',  regular  and  uniform 
in  degree,  of  the  lower  end  of  the  colon.  Indeed,  the  rectum 
and  sigmoid  Hexure  were  found  to  be  defective  in  length, 
and  to  be  represented  by  a  narrow  and  contracted  tube  of 
uniform  calibre. 

On  turning  to  the  recorded  cases,  one  linds  that  such  a 
condition  has  been  noticed  as  a  congenital  defect  in  other 
parts  of  the  intestine,  and  the  narrowing  has  been  found  to 
involve  now  and  then  a  considerable  extent  of  bowel. 

Dodd,"^  for  example,  gives  an  account  of  a  male  infant 
who  lived  for  twelve  weeks,  suffering  all  that  time  from 
much  intestinal  distress.  The  necropsy  showed  that  the 
ascending  and  transverse  parts  of  the  colon  were  through- 
out but  little  larger  than  an  ordinary  lead-pencil.  In  another 
instance  Atkin  t  discovered  the  rectum  and  colon  of  a 
child,  who  lived  for  two  days,  to  be  no  larger  than  an 
ordinary  quill. 

On  reviewing  the  recorded  cases  of  "  idiopathic  dilatation 
of  the  colon "  in  children,  the  following  particulars  call  for 
attention.  Osier  %  narrates  the  histories  of  three  cases 
occurring  in  young  children.  One  was  a  boy,  aged  ten  years, 
who  was  thin,  but  who  presented  an  enormous  abdomen.  He 
had  attacks  of  abdominal  pain  with  vomiting.  Peristaltic 
movements  were  visible  through  the  parietes.  Frequent 
washing  out  of  the  bowel  with  a  long  tube  led  to  some 
slight  relief.  Laparotomy  had  to  be  performed.  There  was 
no  stricture ;  the  sigmoid  ilexure  was  eighteen  inches  in 
circumference ;  the  cfecum  was  half  this  size,  and  the 
bowel  progTessively  increased  in  size  from  the  caecum  to 
the  sigmoid  flexure.  The  distended  bowel  was  folded 
upon  itself,  but  not  so  as  to  cause  any  obstruction.  An 
artificial  anus  was  established.  In  another  case  a  boy, 
aged  three  years,  who  had  been  troubled  with  constipa- 
tion from  birth,  presented  after  death  an  enormously 
dilated  colon,  which  held  fourteen  pints  of  water.  The 
greatest  dilatation   was   about   the   sigmoid  flexure.     Death 

*  Lancet,  ^nne  11,   1892,  p.   1299. 

t  Ibid.,  Jan.  31,   1885,  p.  203. 

X  Archives  of  Pediatrics,  1893,  p.  111. 


252  S  TRIG  TUBE    OF    THE    INTESTINE. 

had  been  due  to  acute  colitis.  The  third  case  was  that  of  an 
infant,  aged  seven  months,  whose  abdomen  was  much  dis- 
tended, and  whose  bowels  never  acted  unless  an  injection  was 
given.  If  the  injection  was  not  administered  daily,  the 
swelling  of  the  abdomen  increased,  and  the  child  vomited. 

Walker*  records  the  case  of  a  child  who  died  from 
emaciation  and  exhaustion  at  the  age  of  eleven  years.  Since 
a  few  weeks  after  birth  enlargement  of  the  abdomen  had  been 
noticed,  and  this  continued  to  increase  as  the  child  grew  up. 
There  was  persistent  constipation.  At  the  necropsy  the 
transverse  and  descending  colon  measured  twenty-three 
inches  in  circumference,  and  looked  "  like  a  large  leg  and 
thigh."  The  commencement  of  the  coecum  and  the 
distal  end  of  the  sigmoid  flexure  are  described  as  normal. 
The  diaphragm  was  so  pushed  upwards  that  its  dome 
was  only  two  and  a  half  inches  from  the  supra-sternal 
notch. 

Formadt  gives  an  account  of  a  man,  aged  twenty-nine 
years,  whose  abdomen  Avas  so  enormous  that  he  was  exhibited 
under  the  title  of  the  "  balloon  man."  The  condition  was  con- 
genital, and  death  was  due  to  sudden  syncope.  The  colon  was 
as  large  as  that  of  an  ox.  Marked  constipation  had  been  the 
symptom  during  life. 

Rolleston  and  Haward  J  record  the  case  of  a  boy,  aged 
twelve  years,  who  had  suffered  from  distension  of  the 
abdomen  and  very  troublesome  constipation  since  he  was 
two  months  old.  On  one  occasion  the  bowels  had  not  acted 
for  nine  weeks.  The  boy  when  seen  was  much  emaciated, 
the  abdomen  was  of  enormous  size,  and  through  the  thinned 
parietes  peristaltic  movements  could  be  seen.  The  abdomen 
was  in  all  parts  tympanitic.  He  had  repeated  obstructive 
attacks,  and  in  one  of  these  he  died.  The  colon  was  found 
at  the  necropsy  to  be  of  normal  size.  The  distension 
mainly  concerned  the  descending  colon  and  sigmoid  flexure 
(Fig  102).  The  rectum  is  said  to  have  been  of  normal 
dimensions.  The  colon  was  much  hypertrophied.  Rolleston 
and  Haward  refer  in  their  paper  to  certain  other  cases  of 
"  congenital  idiopathic  dilatation  of  the  colon." 

Instances  of  early  death — within  eighteen  months  of 
birth — in  cases  associated  with  extreme  dilatation  of  the 
colon  are  given  by  Hirshsprung  §  and  Oestreich.|| 

*£rit.  Med.  Jour.,  vol.  ii.,  1893,  p.  230. 

t  Annual  of  the  IJnivei-sal  Medical  Sciences,  vol.  i.,  1893. 

X  Transactions  of  the  Clinical  Society  of  London,  vol.  xxix. ,  p.  201. 

§  Annual  of  the  Universal  Medical  Sciences,  vol.  i.,  1893. 

11  Berliner  klinische  Wochenschrift,  1893,  p.  852. 


IDIOFATHW    DTLATATIDX    OF    THE    nOLOX. 


All  these  cases  have  certain  veiy  striking  features  in 
common.  Distension  of  the  colon  and  obstinate  constipation 
have  been  noticed  practically  from  birth  ;  the  distension  has 
been  extreme,  and  has  mainly  involved  the  lower  sections  of 
the  colon  ;  the  wall  of  the  dilated  bowel  has  been  greatly 
hypertrophied :  movements  of  the  hypertrophied  coil  have 
been  visible  through  the  parietes  ;  relief  of  the  bowel  has  been 
effected  almost  solely  by  enemata.  Certain  secondary  con- 
ditions, such  as  catarrh  and  ulceration  of  the  distended  gut, 
with  possible  tearing  of  its  walls  in  extreme  cases,  have  been 
noted.  All  the  cases,  except  perhaps  one  in  which  an  artificial 
anus  was  established,  appear  to  have  ended  fatally.  The 
general  circumstances  of  these  cases  do  not  seem  to  be  con- 
sistent with  the  idea  of  an 
"  idiopathic  dilatation  of  the 
colon."  The  very  prominent! 
feature  in  every  example  of  the 
trouble  has  been  some  obstruc- 
tion in  the  lower  part  of  the 
large  intestine.  The  conditions 
presented  are  not  comparable 
with  those  met  with  in  idio- 
pathic dilatation  of  other  parts 
of  the  alimentary  canal  to  which 
attention  has  been  directed.  In 
the  case  which  is  here  reported 
there  was  a  distinct,  even,  and 
extensive  congenital  narrowing 
of  the  lower  extremity  of  the 
colon.  The  symptoms  produced 
were  most  typical  and  entirely 
agreed  with  those  detailed  in 
the  reported  examples. 

I  venture  to  think  that  there 
is  strong  evidence  to  support 
the  suggestion  that  most  cases 
of  "  idiopathic  dilatation  of  the 
colon  "  in  young  children  are 
due  to  congenital  defects  in  the  terminal  part  of  the  bowel, 
that  there  is  in  these  cases  an  actual  mechanical  obstruction, 
and  that  the  dilatation  of  the  bowel  is  not  idiopathic.  The 
marked  hypertrophy  of  the  distended  gut  suggests  in  the 
most  emphatic  way  that  there  is  an  obstruction  to  be 
overcome,  and  such  hypertrophy  is  quite  inconsistent 
with  the  conception  of  an  "  idiopathic "  dilatation  of  the 
bowel. 


Fig.  102. —  Idiopathic  Dilatation 
of  the  Colon.  (Rolleston  and 
HauarcV fi  case.) 

A,  descending  colon ;  h,  caecum ;  i, 
appendix:  c,  sigmoid  flexure; 
L  L,  appendices  epiploicse.  b  to  c 
measured  10  inches,  d  to  f  measured 
5i  inches. 


25 1  STRICTURE    OF    THE    IiYTESTINE. 

Dr.  Cheadle,"^  in  dealing  with  this  subject,  points  out  that 
some  dilatation  is  an  almost  constant  accompaniment  of 
chronic  constipation  in  children.  He  alludes  to  the  case  of  a 
boy,  five  and  a  half  years  old,  who  suffered  from  excessive 
,  dilatation  of  the  colon,  with  constant  vomiting  and  cyanosis. 
The  transverse  colon  was  punctured,  and  the  distension 
was  relieved.  Under  suitable  treatment  the  patient  made  a 
complete  recovery ;  the  distension  did  not  reappear,  and  the 
bowels  in  time  acted  spontaneously  without  aperient  medicines. 

The  following  is  the  case  under  my  care  to  which  allusion 
has  been  made  (page  250) : — 

A  little  girl,  aged  five  years  and  nine  months,  was  brought  to  me 
on  January  5th,  1897.  She  was  the  daughter  of  perfectly  healthy 
])arents,  was  living  in  a  country  district  under  favourable  conditions, 
and  had  been  all  her  life  the  subject  of  the  most  anxious  and  careful 
attention.  She  was  suffering  from  severe  constipation,  which  was 
becoming  almost  insurmountable,  and  which  was  attended  by  frequent 
attacks  of  intestinal  obstruction.  The  child  was  frail  and  delicate- 
looking,  her  face  was  pallid,  and  she  was  thin  almost  to  eniaciation. 
The  abdomen  was  of  enormous  size,  and  was  distended  like  a  balloon. 
It  was  everywhere  uniformly  tympanitic,  and  exhibited  precisely  the 
condition  described  under  the  title  of  idiopathic  dilatation  of  the 
colon.  Through  the  thinned  parietes  an  enormous  coil  of  intestine, 
evidently  colon,  could  be  seen.  It  appeared  to  occupy  almost  tlie 
whole  abdominal  cavity.  It  was  the  seat  of  certain  visible  peri- 
staltic movements,  which,  however,  were  occasional  only.  The  tongue 
was  foul,  and  the  breath  was  offensive.  The  appetite  was  excellent. 
The  bowels  never  acted  naturally,  and  a  motion  was  only  obtained  by 
passing  a  rigid  tube  some  ten  inches  beyond  the  anus  and  then 
administering  an  enema.  There  was  considerable  pain  in  the  abdomen. 
The  anus  was  very  small,  and  a  digital  examination  of  the  rectum 
without  an  aniBsthetic  was  quite  impossible. 

The  history  given  was  as  follows : — The  child  was  born  in  March, 
1891.  Two  days  after  birth  vomiting  commenced,  and  continued  off  and 
on  for  several  days  ;  the  bowels  ceased  to  act ;  and  some  distension  of 
the  abdomen  became  evident.  Aperient  medicine  had  no  effect,  and 
relief  was  ultimately  obtained  by  enemata.  Like  attacks,  marked  by 
vomiting,  absolute  constipation,  and  distension  of  the  abdomen,  occurred 
in  July,  August,  and  September  of  the  same  year.  At  the  end  of  1891 
there  was  a  very  severe  attack,  in  which  the  patient's  life  seems  to  have 
been  in  danger.  The  distension  of  the  abdomen  became  excessive  and 
permanent,  the  bowels  only  acted  after  enemata,  and  when  enemata 
failed  vomiting  and  increased  distension  appeared  until  relief  was 
obtained.  Aperient  medicines  proved  to  be  valueless,  and  were  finally 
quite  abandoned.  Massage  and  other  measures  were  tried,  but  without 
effect.  In  August,  1 894,  relief  of  the  bowel  was  attempted  by  means 
of  enemata  given  through  a  long  rigid  tube  passed  some  ten  inches  into 
the  bowel.  This  measure  was  so  successful  that  for  ten  months  the 
child  had  only  two  or  three  obstructive  attacks,  although  the  distension 
of  the  abdomen  persisted  and  remained  very  considerable.  In  July 
and  November,  1895,  there  were  severe  and  alarming  attacks  of  in- 
testinal obstruction,  which  finally  yielded  to  enemata  by  means  of  tlie 
*  Zmcet,  Feb.  5,  1898,  p.  399. 


IDIOPATHIC    DILATATION    OF    THE    COLON.         255 

long  tube.  Up  to  this  time  there  had  been  comparatively  little  com- 
plaint of  abdominal  pain.  In  1896  the  child  began  to  suffer  from 
cramping  pains  in  the  abdomen  which  increased  in  severity  as  time 
went  on,  and  which  were  evidently  due  to  disorderly  peristaltic  move- 
ments in  the  now  much  hypertrophied  bowel.  Gurgling  and  bubljling 
sounds  could  l)e  heard  in  the  abdomen,  and  sounds  as  of  the  dropping 
of  water.  The  attacks  of  obstruction  becauie  more  freciuent,  and  were 
of  longer  duration.  The  distension  of  the  abdomen  became  enormous, 
and  when  the  distension  was  at  its  maximum  the  child  was  unable  to 
move.  Enemata — no  matter  how  administered — were  now  losing  their 
effect,  no  aperients  could  be  tolerated,  and  the  condition  of  the  child 
when  .she  came  under  my  notice  was  certainly  very  deplorable. 

I  performed  lajjarotomy  on  January  13th,  1897,  opening  the  abdomen 
in  the  median  line  below  the  umbilicus.  There  immediately  presented 
a  gigantic  coil  of  colon  which  looked  and  felt  like  the  adult  stomach 
and  which  appeared  to  fill  u]i  the  whole  of  the  abdomen.  This  coil  w-as 
at  once  emptied  of  its  gas  through  a  small  incision.  The  wall  of  this 
intestine  was  smooth  and  nuicli  thickened  by  hypertrophy,  and  the 
actual  diameter  of  the  collapsed  loop  wa.s  eight  inches.  It  was  this 
coil  which  had  practically  alone  caused  the  distension  of  the  abdomen. 
Further  examination  .showed  that  the  lower  part  of  the  bowel  corre- 
sponding to  the  rectum  and  sigmoid  flexure  was  represented  by  a 
straight,  solid-looking  tube  about  the  size  of  an  adult's  forefinger  and 
some  eight  or  nine  inches  in  length.  This  tube  was  without  saccula- 
tion, and  its  longitudinal  muscular  coat  was  very  marked.  It  was  of 
uniform  diameter.  It  was  provided  throughout  with  a  short  meso- 
colon. There  was  scarcely  a  trace  of  fat  within  the  abdomen,  and  as  a 
residt  the  blood-vessels  of  the  intestine  were  easily  identified.  The  left 
colic  artery,  much  increased  in  size,  went  to  the  dilated  loop  of  the 
colon,  while  the  sigmoid  branch  of  the  inferior  mesenteric  artery  ran 
to  the  narrowed  tube  below  the  dilatation.  The  junction  between  the 
dilated  gut  and  the  narrow  tube  w^as  cjuite  abrupt.  I  enlarged  the 
little  opening  I  had  made  into  the  colon,  and  introduced  the  finger  to 
examine  the  interior  of  the  great  pouch.  Its  walls  were  smooth,  and 
a  flap-like  fold  of  mucous  membrane  occupied  the  orifice  that  led  into 
the  narrow  tube.  This  opening  readily  took  the  forefinger.  The  fold 
of  mucous  membrane  may  have  contributed  to  certain  of  the  obstructive 
attacks,  and  may  explain  the  retention  of  certain  enemata.  In  examin- 
ing the  parts,  however,  it  appeared  more  probable  that  the  attacks 
of  obstruction  were  due  to  bending  or  kinking  of  the  bowel  at  the 
point  where  the  tube  and  the  great  sac  joined.  The  length  of  the 
narrowed  part  of  the  bowel  corresponded  to  the  length  of  tube  which 
experience  had  sliow^n  was  necessary  to  produce  any  emptying  of  the 
great  pouch.  The  even  contraction  of  the  lower  part  of  the  bowel  may 
have  been  in  some  degree  due  to  the  constant  use  of  this  tube.  I 
passed  a  gum-elastic  tube  of  large  calibre  through  the  anus,  and  along 
the  narrowed  rectum  well  into  the  interior  of  the  dilated  bowel.  The 
tube  measured  twelve  inches.  I  had  some  hope  that  if  it  could  be 
kept  in  position  for  a  time  the  distension  would  be  relieved,  and  a 
more  normal  action  of  the  bowels  would  be  possible.  I  closed  the 
opening  I  had  made  into  the  descending  colon,  but  brought  the  suture 
line  into  the  centre  of  the  parietal  wound  so  that  an  artificial  anus 
could  be  established  at  any  moment.  This  fixing  of  the  bowel  would, 
I  hoped,  tend  to  prevent  it  from  becoming  kinkecl  or  bent.  The  wound 
in  the  parietes  was  then  closed  in  all  but  its  central  parts. 

For  some  days  the  abdomen  remained  free  from  distension  and  the 


256  STRICTURE    OF    THE    INTESTINE. 

cliild  fi'oni  pain.  Some  faecal  matter  was  passed,  but  in  due  course  the 
gum  elastic  tube  became  blocked  and  could  not  be  freed  ;  another  tube 
could  uot  be  properly  introduced,  the  child  felt  the  worry  of  a  foreign 
body  in  the  bowel,  and  at  the  end  of  seven  days  the  use  of  the  tube 
was  abandoned,  and  au  artificial  anus  established  in  the  centre  of  the 
median  wound.  Through  this  artificial  opening  all  the  motions  were 
passed  for  the  next  nine  months.  Practically  nothing  came  by  the 
rectum.  The  distension  was  relieved,  and  the  child  was  free  from  the 
continued  spasmodic  pains.  There  was,  however,  some  difficulty  in 
keeping  the  artificial  anus  open,  as  there  always  is  with  such  openings 
when  made  as  the  present  one  was  made.  This  necessitated  the  intro- 
duction for  so  many  hours  each  day  of  a  bent  rubber  tube  which  kept 
the  orifice  quite  patent,  but  which  occasioned  the  child  a  good  deal  of 
distress.  In  October,  1897,  I  resolved  to  attempt  the  excision  of  the 
colon  from  the  splenic  flexure  to  the  anus,  as  this  appeared  to  affoi-d 
tlie  only  possible  prospect  of  giving  complete  relief  to  what  was  still 
a  distressing  condition. 

The  second  operation  was  performed  on  October  29th.  By  means 
of  an  elliptical  incision  in  the  skin  I  isolated  and  removed  the  artificial 
anus,  entering  the  abdomen  on  each  side  of  the  opening.  The  orifice  in 
the  colon  I  closed  by  a  series  of  substantial  sutures.  1  found  that  the 
gut,  which  had  at  one  time  been  so  enormously  distended,  was  now  of 
more  moderate  dimensions,  and  its  point  of  junction  with  the  narrow 
tube  which  represented  the  lower  part  of  the  colon  was  still  abrupt. 
The  narrowed  tube  had  shortened  somewhat  as  the  result  of  removing 
the  distension.  The  dilatation  of  the  colon  extended  up  to  the  splenic 
flexure.  Beyond  that  point  the  colon  was  practically  normal,  although 
it  had  evidently  been  to  some  degree  distended  and  still  showed  some 
hypertrophy  of  its  walls.  The  colon  on  the  right  side  was  normal,  and 
the  whole  of  the  greater  bowel  had  a  very  free  mesocolon.  Having 
found  that  I  could  bring  the  left  extremity  of  the  transverse  colon  to 
the  anus,  I  isolated  and  ligatured  the  left  colic  artery,  and,  having 
clamped  the  bowel,  divided  it  at  the  splenic  flexure.  I  then  isolated 
the  sigmoid  artery  and  the  superior  hasmorrhoidal  vessels  and  ligatured 
them.  The  absence  of  fat  in  the  retroperitoneal  tissue  rendered  this 
proceeding  very  simple.  At  the  same  time  I  ascertained  that  the  dis- 
tribution of  the  middle  and  right  colic  arteries  was  normal.  I  then 
excised  the  gut  representing  the  descending  colon,  the  sigmoid  flexure, 
and  the  upper  part  of  tlie  rectum.  I  divided  the  bowel  low  down  in 
the  pelvis  below  the  entrance  of  the  superior  hsemorrhoidal  artery.  A 
few  bleeding  points  made  manifest  by  the  excision  required  ligatures. 
The  child  was  now  placed  in  the  lithotomy  position,  and,  having  made 
an  elliptical  incision  around  the  evidently  narrowed  anus,  I  proceeded 
to  remove  the  anus  together  with  the  lower  and  remaining  portion  of 
the  rectum.  The  separation  of  the  rectum  from  the  slender  vagina 
was  a  somewhat  tedious  matter.  The  middle  haemorrhoidal  vessels 
were  secured  and  the  lower  end  of  the  rectum  removed  without 
difficulty.  I  returned  to  the  abdominal  cavity  and  brought  the  trans- 
verse colon  down  to  the  anus,  where  I  secured  it  by  a  series  of  close 
sutures.  The  gut  was  conducted  into  position  by  four  pressure  forceps 
which  were  passed  into  the  abdomen  through  the  hole  in  the  perineum. 
The  operation  was  concluded  by  closing  the  wound  in  the  abdomen 
without  drainage. 

The  child  made  a  speedy  and  excellent  recovery.  No  sedative  of 
any  kind  was  needed,  as  little  pain  was  complained  of.  She  was  once 
sick.      The  only  complication  was   represented  by  some  suppiu'ation 


IDIOPATHIC    DILATATION    OF    THE    COLON:         257 

between  the  new  rectum  and  the  vagina.  This  was  no  doubt  due  to 
accidental  infection  of  the  tissues  while  drawing  the  transverse  colon 
into  place.  As  soon  as  the  child  began  to  run  about  again  this 
discharge  ceased  entirely.  The  bowels  began  to  act  without  any 
difficulty,  and  in  the  course  of  some  months  the  child  had  control  over 
the  new  anus. 

It  is  quite  clear  that  in  this  particular  instance  the  dilatation  of  the 
colon  was  due  to  a  congenital  narrowing  of  the  lower  extremity  of  the 
bowel,  as  represented  by  the  segment  supplied  by  the  inferior  mesen- 
teric artery.  This  narrowed  part  exhibited  no  structural  change.  The 
specimen  is  in  the  museum  of  the  lloyal  College  of  Surgeons  of 
England.  Little  idea  of  the  immense  degree  of  dilatation  of  the  colon 
can  he  gathered  from  the  preparation  as  it  now  appears.  The  junction 
of  the  narrowed  portion  with  the  dilated  part  is  not  so  abrupt  as  it 
appeared  to  be  before  the  intestine  was  removed.  At  this  point  of 
junction  there  is  no  mechanical  obstruction  and  no  disease  of  either 
mucous  or  muscular  coats.  In  mounting  the  preparation  the  structures 
which  formed  the  anus  have  been  removed. 

This  is,  I  believe,  the  first  instance  in  which  this  con- 
dition has  been  treated  by  a  radical  operation. 

Treatment. — The  treatment  of  the  so-called  "  idiopathic 
dilatation  of  the  colon  "  may  be  considered  generally,  and  with 
reference  to  both  classes  of  case. 

1.  The  digestion  must  be  attended  to,  and  the  diet  care- 
fully regulated,  with  the  idea  of  allowing  as  little  debris  as 
possible  to  reach  the  colon. 

2.  Every  attempt  must  be  made  to  secure  a  regular  action 
of  the  bowels.  In  effecting  this  end  aperients,  and  especially 
saline  aperients,  may  be  of  service,  but  it  is  not  unusual  to 
find  that  they  are  often  unavailing.  The  chief  measure  of 
treatment  will  consist  in  the  frequent  washing  out  of  the  colon. 
This  is  most  conveniently  done  with  an  irriga!:or  raised  to 
some  height — say  three  feet — above  the  bed,  and  the  patient 
at  the  time  should  be  made  to  occupy  the  knee  and  left 
shoulder  position  if  possible. 

Massage,  electricity,  and  strychnia  have  all  been  of  value 
in  promoting  an  action  of  the  bowels.  Salol  or  /3  naphthol 
may  be  of  service  in  diminishing  flatulence. 

The  passing  of  the  long  tube  has  now  and  then  led  to  the 
emptying  of  the  distended  loop,  and  enemata  given  with  a 
long  firm  tube  have  answered  when  others  have  failed,  but, 
on  the  whole,  the  long  tube  is  not  efficient.  The  difficulty  of 
passing  it  is  very  considerable,  the  point  to  which  it  reaches 
is  uncertain,  and  just  as  the  tube  is  supposed  to  have  reached 
the  descending  colon,  its  extremity  may  appear  at  the  anus 
owing  to  its  having  been  doubled  upon  itself. 

3.  Of  operative  measures  there  is  little  to  commend  tap- 
ping or  aspiration  of  the  bowel. 

In  most  instances  in  which  it  has  been  employed,  it  has 

R 


258  STRIGTUBE    OF    THE    INTESTINE. 

resulted — as  may  have  been  supposed — in  onl}''  temporary 
relief.  The  tappings  have  been  repeated  many  times  over, 
but  with  no  more  than  a  few  hours'  relief  to  the  distension. 
As  the  dilated  bowel  is  often  ulcerated,  and  perhaps  deeply 
ulcerated,  the  little  operation  is  not  without  danger. 

In  Dr.  Cheadle's  case,  the  dilated  colon  was  punctured,  and 
after  suitable  treatment,  a  complete  cure  followed,  but  cases 
such  as  these  are  rare. 

In  cases  which  have  resisted  other  measures  an  artificial 
opening  into  the  colon  should  be  made.  It  need  only  be  of 
small  size  to  allow,  in  the  first  instance,  of  the  escape  of 
gas.  Every  attempt  should  be  continued  to  enable  the 
patient  to  make  use  of  the  rectum. 

When  actual  intestinal  obstruction  exists,  there  is  nothing 
to  be  done  but  to  make  at  once  a  free  opening  into  the  coloirj.'. 
That  opening  may  or  may  not  be  closed  according  to  the 
circumstances  of  the  case. 

As  all  these  cases  of  "  idiopathic  dilatation  of  the  colon  " 
have,  with  only  a  few  solitary  exceptions,  ended  in  death, 
,and  as  the  dilated  bowel  is  very  apt  to  give  way,  this 
somewhat  forbidding  operation  should  not  be  too  long 
delayed. 

In  a  few  instances,  a  radical  operation  may  be  possible, 
in  the  form  of  an  excision  or  an  anastomosis.  For  such 
cases  no  rules  can  be  laid  down.  I  have  already  given  an 
instance  in  which  a  liberal  excision  of  the  colon  led  to 
.  complete  recovery. 


259 


CHAPTER  IX. 

OBSTRUCTION"  DUE  TO  TUMOURS  GROWING  FROM  THE 
BOWEL  WALL. 

Cancer  of  the  bowel,  wliicli  has  been  fully  described  in 
the  section  on  stricture  of  the  intestine,  may  form  a  definite 
tumour,  which  may  project  into  the  lumen  of  the  tube,  and 
cause  obstruction.  Such  a  method  of  obstructing  the  bowel 
is,  however,  not  common  in  cancer,  and  as  the  matter  has 
been  dealt  with  in  the  section  named  (page  220),  carcinoma 
may  be  excluded  from  the  "  tumours "  which  are  now  to  be 
described. 

The  tumours  considered  in  this  chapter  comprise  a  variety 
of  innocent  neoplasms,  together  with  lymphadenomata,  and 
sarcomatous  tumours. 

They  are  all  comparatively  uncommon,  they  but  seldom 
cause  an  obstruction  in  the  bowel,  and  they  are  of  but  little 
clinical  interest. 

The  innocent  tumours  may  first  be  considered. 

1.  Adenomata. — These  grow  from  the  mucous  membrane, 
and  have  their  origin  in  the  follicles  of  Lieberktihn  or  in 
Brunner's  glands.  They  present  on  section  a  number  of  tubes, 
passages,  and  spaces,  all  lined  with  columnar  epithelium  and 
supported  by  connective  tissue  which  may  vary  in  structure 
from  a  lax  myxomatous  meshwork  to  a  substantial  fibrous 
substance.  It  is  upon  the  character  of  this  supporting  tissue 
that  the  physical  features  of  the  growth  in  some  part  depend, 
the  laxer  tissues  forming  soft,  and  the  denser  structures 
firm,  polypoid  masses.  They  vary  in  size  from  a  pea  to  a 
Avalnut.  Some  few  have  been  described  as  as  large  as  a  pear. 
The  mode  of  origin  of  these  growths  has  been  very 
elaborately  described  by  Mr.  Harrison  Cripps,  in  regard,  at 
least  to  their  appearance  in  the  rectum.  It  would  seem 
that  the  line  of  demarcation  between  them  and  the  cylindrical 


260  OBSTRUCTION  DUE    TO    TUMOURS. 

epitheliomata  is  often  faint,  and  that  one  species  of  growth 
may  shade  off  into  the  other.  This  very  especially  applies  to 
the  rectum  {see  an  excellent  case  by  Dr.  Handford ;  Path. 
Soc.  Trans.,  1890,  page  133). 

The  majority  of  these  growths  assume  the  aspects  of  a 
projecting  tumour,  and  have  been  described  under  the 
names  of  papilloma,  fibrous  or  mucous  papilloma,  benign 
villous  polyp  and  the  like.  Sometimes  the  neoplasm  spreads 
laterally  under  the  immediate  surface  of  the  mucous  mem- 
brane, producing  the  growth  known  as  a  "  flat  adenoma."^ 
Others  appear  as  sessile  nodules. 

These  adenomata  have  been  found  in  all  parts  of  the 
intestine,  but  are  most  frequently  met  with  in  the  rectum 
and  colon,  and  form  the  commonest  variety  of  benign  growth. 
They  frequently  occur  in  children,  and  are  perhaps  more 
often  multiple  than  single. 

In  appearance  the  adenomata  are  red  and  soft  like  vascular 
mucous  membrane.  Some  are  smooth  upon  the  surface 
others  have  a  cauliflower-like  or  papillomatous  surface. 


Fig,  103. — Polypus-like  projections  from  the  Mucous  Membrane  of  the  Colon- 
Great  thickening  of  the  mucous  membrane  {Royal  Coll.  of  Surg.  Mus.,  Xo.  2455  A). 


ADENOMATA.  261 

An  excellent  description  of  a  case  of  multiple  polypi  of 
the  small  intestine  is  given  by  Kanthack  in  the  Pathological 
Societj^'s  Transactions,  1897,  page  83. 

Some  intestinal  "  polyps  "  have  contained  muscular  tissue. 

In  Guy's  Hospital  Museum  is  a  "  polyp  "  ot  the  ileum, 
which  contains  a  central  mass  of  fat.  It  is  supposed  to  have 
had  its  origin  in  the  invagination  of  a  Meckel's  diverticulum. 
In  Handford's  case,  above  alluded  to,  the  colon  contained 
170  polypi. 

To  those  growths  from  the  mucous  membrane  of  the  bowel 
which  assume  a  marked  papillary  character,  the  name  of 
papillomata,  or  polypoid  vegetations,  has  been  given.  Such 
growths  are  rare,  are  most  common  in  the  rectum  and  lower 
colon,  and  are  very  apt  to  be  multiple.  Luschka  reports  the 
•case  of  a  woman  aged  thirty,  whose  whole  colon  was  studded 
with  thousands  of  these  so-called  vegetations. 

That  these  growths  may  become  epitheliomatous  has  been 
fully  demonstrated. 

They  often  appear  to  occur  in  certain  families.  I  have 
seen  a  brother  and  sister  affected  with  this  condition."^  They 
are  fully  described  in  works  on  Diseases  of  the  Rectum ;  also 
reference  may  be  made  to  an  excellent  resume  in  Maylard's 
"Surgery  of  the  Alimentary  Canal,"  page  603.  Multiple 
papillomata  have  been  met  with  in  the  duodenum. 

Fig.  103  shows  numerous  polypoid  projections  from  the 
surface  of  the  colon,  attended  with  great  thickening  of  the 
mucous  membrane. 

A  valuable  account  of  a  case  of  multiple  papillomata  of 
the  colon  in  a  man  aged  twenty-eight  is  given  by  Dalton.t 

2.  Congenital  Cysts.  —  Rokitansky  and  others  have 
described  cases  where  onultilocular  cysts  filled  vAth  serum 
were  found  partly  embedded  in  the  intestinal  wall. 

Letulle  gives  an  account  of  a  case  of  this  kind  in  which 
from  300  to  400  cysts  were  discovered. 

Roth  found  a  cyst  lined  with  ciliated  epithelium. J 

Dr.  Sainsbury  §  describes  a  case  in  a  girl,  aged  eleven, 
who  died  from  typhoid  fever.  In  the  commencement  of 
the  ascending  colon  a  cyst,  the  size  of  a  duck's  egg,  was 
discovered.  It  w^s  connected  with  the  ileo-C8ecal  valve. 
The  outer  wall  was  formed  of  mucous  membrane,  and  the 
lining  or  inner  wall  of  serous  membrane  {see  page  272). 

*  See  cases  quoted  in  St.  Bart.'s  Hospital  Reports,  1887,  p.  225  ;  and  1890> 
p.  299. 

t  Path.  Soc.  Trans.,  1893,  p.  85. 

X  Virchow's  Archiv,  Bd.  86,  p.  371: 

§  Path.  Soc.  Trans.,  1887,  p.  146.  See  also  case  in  Path.  Soc,  Trans., 
1885,  p.  213. 


262  OBSTRUCTION  DUE    TO    TUMOURS. 

Buchwald"^  describes  the  case  of  a  boy  who  died  of 
obstruction.  The  autopsy  revealed  two  cysts  in  the  wall  of 
the  jejunum.  Accounts  of  cysts  in  the  rectum  are  fur- 
nished by  Prideaux,t  Adams, J  and  others. 

In  a  few  instances  dermoid  cysts  have  been  met  with 
in  the  colon  and  rectum.  In  a  case  reported  by  Mr. 
Glutton, §  a  pedunculated  dermoid  cyst  growing  from  the 
sigmoid  flexure  protruded  at  the  anus.  It  measured  three 
inches  in  its  longest  diameter.  It  was  covered  with  hair, 
and  resembled  a  child's  scrotum.  It  contained  fat,  fibrous 
tissue,  bone  and  hair  nine  to  ten  inches  in  length.  The 
patient  was  a  girl  between  eight  and  nine  years  of  age, 
who  suffered  from  straining  and  tenesmus.  The  dermoid 
had  suppurated,  and,  some  time  before  the  operation, 
pus  was  discharged  by  the  rectum.  Dr.  Port  1|  has  recorded 
a  case  which  very  closely  resembles  the  one  just  described. 
The  patient  was  a  girl  of  sixteen,  who  suffered  much  from 
tenesmus.  A  dermoid  cyst  ultimately  protruded  at  the 
anus,  and  was  removed.  The  tumour  contained,  in  addi- 
tion to  bone  and  hair,  a  canine  tooth. 

3.  Fibromata. — Fibrous  tumours  have  been  met  with 
in  the  bowel,  growing  from  the  submucous  tissue.  They 
usually  appear  as  polypi,  and  are  most  common  in  the 
rectum.  They  have  also  been  met  with  in  the  colon  and 
ileum.  Hale  White  ^  describes  a  fibrous  polyp  of  the 
jejunum,  which  caused  a  fatal  intussusception.  The  recorded 
cases  vary  from  an  instance  in  which  a  little  fibroma,  the 
size  of  a  pea,  was  found  in  the  csecum,^'^  to  a  case  in  which 
a  polyp  composed  of  connective  tissue  was  found  in  the 
rectum,  which  was  the  size  of  a  foetal  head,  and  weighed 
nearly  two  pounds.ft  In  a  few  instances  a  polypoid  mass, 
composed  of  myxomatous  tissue,  has  been  found  in  the  rectum. 

4.  Fibro-myomata. — -Tumours  composed  of  unstriped 
muscular  tissue  or  of  a  mixture  of  such  muscle  with 
fibrous  tissue  are  met  with  in  the  bowel.  They  tend  to 
become  polypoid,  and  are  assumed  to  have  their  origin  in 
the  muscular  coat.  These  tumours  have  been  mostly  met 
with  in  the  rectum.     McCoshJJ  records  the  case  of  a  man 

*  Annual  of  the  Universal  Med.  Sci.,  1888,  vol.  i.,  p.  357. 
t  Icmcef,  1883,  vol.  ii.,  p.  633. 
+  Zond.  Med.  Record,   1881,  p.  881. 
§  Path.  Soo.  Trans.,   1886,  p.  252. 

il  Ibid.,  1880,  p.  .307.  Another  case  is  recorded  by  Denzil,  Archiv  fiir 
klin.  Chir.,  1874,  p.  442. 

t  Path.  Soc.  Trans.,   1890,  p.   121. 
**  Dr.  Percy  Kidd;  Ibid.,  1885,  p.  210. 
ft  Mr.  Bowlby;  Ibid.,  1883,  p.  106. 
XX  Annals  of  Surgery,  1893,  p.  41. 


FIBRO-MTOMATA.  263 

of  thirty-four,  wlio  for  years  had  had  increasing  difficulty 
with  the  bowels.  The  fseces  passed  were  either  fluid  or 
were  flattened  out  into  ribbons.  A  tibro-myonia  was  dis- 
covered growing  from  the  rectum,  and  was  removed.  It 
was  the  size  and  very  much  the  shape  of  a  large  cocoa-nut. 
A  tumour  described  as  a  myoma  growing  from  the  small 
intestine  appears  to  have  led  to  fatal  heemorrhage.^ 

5.  Lipomata. — These  growths  spring  from  the  submucous 
layer,  take  a  polypoid  form  as  a  rule,  and  are  often  multiple. 
Sometimes  they  may  attain  considerable  size.f 

General  Account  of  Benign  Polypi. — Considered  collec- 
tively, benign  tumours  of  the  intestine  are  usually  met  with 
in  the  form  of  polypi.  As  such  they  may  have  very  distinct 
pedicles.  In  a  case  of  Sir  Prescott  Hewett's  the  pedicle  was 
the  size  of  the  finoer  and  one  inch  and  a  half  in  length. 
In  shape  they  are  round,  oval,  or  pear-shaped.  In  size  they 
vary  from  the  dimensions  of  a  pea  to  that  of  a  small  orange, 
a  pear,  or  a  cocoa-nut.  They  are  usually  covered  by  normal 
mucous  membrane,  which  may,  however,  be  in  a  condition 
ot  ulceration.  As  regards  their  place  of  origin,  the  great 
majority,  probably  not  less  than  80  per  cent,  are  met  with 
in  the  rectum.  Next  in  frequency  come  the  ileum  and 
colon.  They  are  rare  in  the  jejunum  and  still  rarer  in  the 
duodenum.  As  regards  the  small  intestine,  the  favourite  site 
is  in  the  lower  extremity  of  the  ileum. 

The  growth  is  usually  attached  to  the  convex  border  of 
the  gut,  or  at  least  away  from  the  mesenteric  border.  It 
is  not  uncommon  for  the  polyp  to  drag  in  that  part  of 
the  intestinal  wall  to  which  it  is  attached,  and  so  produce  a 
depressicn  or  umbilicus  upon  the  surface  of  the  gut.  In  one 
case,  where  an  intussusception  had  been  produced,  this 
depression  was  sufficiently  deep  and  definite  to  admit  the 
tip  of  the  little  finger,  j 

Benign  polypi  are  often  very  numerous.  Allusion  has 
already  been  made  to  instances  of  this.  The  occurrence  of 
three,  four,  or  five  polypi  in  the  same  division  of  the  bowel 
is  quite  common. 

Benign  growths  of  the  intestine  may  give  rise  to  no 
symptoms  during  life,  and  may  even  attain  large  size  and 
become  quite  numerous  without  affording  any  evidence  of 
their  existence.     Thus,  in  two  cases  of  very  large  polypi  of 

*  Dr.  Mercer ;  Annual  of  the  Universal  Med.  Sci.,  1889,  vol.  i.,  D-15. 

t  A  specimen  oi:  a  lipoma  will  be  found  in  the  Lend.  Hosp.  Museum.  No. 
Ae  45.  See  case  of  lipoma  of  sigmoid  flexure  by  Yoss  ;  Zond.  Med.  Record.  1881, 
p.  200. 

t  M.  Fernet ;  Bull,  de  la  Soc.  Anat.,  1863,  p.  296. 


264  OBSTRUCTION   DUE    TO    TUMOURS. 

the  ileum,  reported  by  Sir  Prescott  Hewett,  no  symptoms 
appear  to  have  been  induced  until  an  intussusception  arose. 
One  of  these  growths  was  as  large  as  a  pear,  the  other 
measured  two  and  three-quarters  inches  by  one  inch  and 
a  half.^  Polypi  most  usually  cause  symptoms,  when  in 
the  rectum,  producing  tenesmus,  bleeding  Irom  the  bowel, 
difficult  defsecation  and  a  sense  of  a  foreign  substance  in  the 
gut.  The  same  symptoms  in  a  less  marked  degree  may 
attend  growths  arising  from  the  sigmoid  flexure. 

Now  and  then  innocent  tumours  of  the  rectum  have 
caused  actual  chronic  intestinal  obstruction,  the  bowel  being 
more  or  less  completely  blocked  by  the  growth. 

Dr.  Foxwell  t  describes  the  case  of  a  large  myxo- 
fibromatous  polyp  three  times  the  size  of  a  chestnut,  which 
was  discovered  post-mortem  in  the  body  of  a  woman  of 
twenty-eight.  During  life  it  had  caused  the  symptoms  of 
pyloric  obstruction. 

In  other  parts  of  the  intestine  the  polyp  usually  causes 
obstruction,  if  it  occlude  the  gut  at  all,  by  mducing  an 
invagination.  This  is  particularly  the  case  with  such  as 
grow  from  the  ileo-csecal  valve  and  from  the  terminal  part 
of  the  ileum.  Benign  tumours  have  also  produced  intussus- 
ceptions in  other  parts  of  the  bowel,  in  the  rectum,  in  the 
sigmoid  flexure,  and  in  all  parts  of  the  colon. 

When  the  mass  is  of  large  size,  or  when  the  growths  are 
multiple,  symptoms  of  obstruction  may  be  produced  that 
more  or  less  closely  resemble  the  symptoms  of  stricture, 
save  that  they  are  usually  more  chronic  and  for  a  while 
at  least  less  marked.  Some  of  the  most  marked  examples 
of  this  form  of  obstruction  have  been  met  with  in  con- 
nection with  growths  springing  from  the  margin  of  the 
ileo-csecal  valve. 

So  far  as  I  am  aware,  it  would  be  impossible  to  diagnose 
cases  of  obstruction  due  to  simple  neoplasms  from  cases 
of  stricture.  I  can  find  no  instance  recorded  where  the 
growth  was  felt  through  the  parietes  during  life,  except, 
perhaps,  when  associated  with  an  invagination. 

In  a  few  cases  the  polyp  has  separated  from  its  attach- 
ment and  has  been  passed  per  anum.  This  mostly  occurs 
in  connection  with  such  growths  as  spring  from  the  rectum 
or  sigmoid  flexure ;  although  I  am  disposed  to  believe 
that  some  re]3orted  cases  where  strange  fleshy  masses  have 
been  passed  with  motions  might  have  been  examples  of 
the  spontaneous  removal  of  a  polyp.     An  excellent  example 

*  Path.  Soc.  Trans.,  vol.  i.,  p.  95. 
t  Lancet,  vol.  i.,  1889,  p.  1239. 


LYMPH  AD  EXOM ATA.  265 

of  the  separation  of  such  a  tumour  from  the  sigmoid  flexure, 
or  rectum,  is  reported  by  M.  Afezou.  It  concerned  an  old 
woman,  aged  eighty-three,  who  had  been  troubled  for  a 
number  of  years  with  indigestion,  attacks  of  colic  and  consti- 
pation alternating  with  diarrhcea.  At  last  the  constipation 
became  so  j)i*oiiounced  that  no  relief  to  the  bowel  could 
be  obtained  except  by  enemata.  One  day  after  an  examina- 
tion of  the  bowel  a  soft  mass  was  passed.  It  proved  to  be 
a  lipomatous  polyp.  All  the  patient's  intestinal  troubles 
at  once  ceased,  and  the  bowels  became  regular  again.'^ 

6.  Lymphadenomata. — Many  examples  of  lymphade- 
noma,  or  lympho-sarcoma,  in  the  intestine  have  been  recorded. 
The  neoplasm  appears  in  the  adenoid  tissue  of  the  bowel, 
and  may  attain  considerable  dimensions.  It  is  remarkable 
that  in  spite  of  the  great  size  the  growth  may  reach, 
obstruction  of  the  intestine  is  very  rare.  The  lymphoid 
growth  may  be  found  in  any  part  of  the  alimentary  canal. 
It  may  be  found  scattered  about  through  the  stomach  and 
the  whole  length  of  the  intestine.  It  is  much  more  common 
in  the  small  intestine  than  in  the  large,  and  is,  indeed,  rare 
in  the  colon  alone. 

Among  eighteen  recorded  cases  the  distribution  of  the 
lymphoid  growth  is  as  follows : — 


Stomach,  small  intestine  and  colon 
Stomacli  and  small  intestine 
Small  intestine  and  colon    . 
Small  intestine      .... 
Colon 


5  cases. 
1  case. 
3  cases. 


1  case. 


18 
The  ileo-csecal  region  is  a  part  very  conspicuously  affected, 
and  it  is  in  this  region  that  the  growth  is  apt  to  reach  its 
largest  proportions. 

In  the  bowel  it  would  appear  that  lymphadenoma  when 
it  occurs  is  usually  primary. 

"  Cases  of  lymphadenoma  of  the  intestinal  tract,"  writes 
Dr.  Xewton  Pitt,t  "  seem  to  fall  into  two  great  groups — 
those  in  which  the  growths  commence  in  the  mucous  and 
submucous  coats,  and  form  tumours  projecting  into  the 
lumen  of  the  bowel;  and  those  in  which  the  growth  forms 
a  diffused  sheath,  extending  along  the  subserous  surface, 
and  but  occasionally  reaching  the  mucous  and  submucous 
coats.  They  seem  to  correspond  to  the  two  groups  of 
lymphoid    tissue :     the    follicles    and     lymphatics    of     the 

*  Bull,  de  la  Soc.  Anat.-,  1875,  p.  195. 
t  Path.  Soc.  Trans.,  1889,  p.  80. 


266 


OBSTRUCTION'  DUE    TO    TUMOURS. 


mucous    membrane,   and    tlie   lymphatics  oi    the   musculc^- 

and  subserous  coats. 

"  The  former  do  not  alter  the  calibre  of  the  bowel,  and  b'^i 

rarely  ulcerate.  Their 
seats  of  election  appear 
to  be  the  lymphoid  areas 
of  the  verndform  appen- 
dix, the  ileo-csecal  valve, 
Peyer's  patches,  and  the 
solitary  follicles  of  the 
small  intestine  [Fig. 
104] ;  more  rarely  the 
duodenum,  the  cardiac 
end  of  the  stomach,  and 
the  tonsils.  The  oeso- 
phagus and  large  intes- 
tine have  entirely 
escaped  in  some  cases. 

"  In  the  latter  group 
the  growth  forms  a 
sheath,  which  invades 
the  muscular  coat,  para- 
lyses it,  and  hence  leads 
to  dilatation ;  the  growth 
where  it  reaches  the 
surface  of  the  bowel  is 
apt  to  ulcerate,  probably 
because  its  vascular  sup- 
ply is  more  defective 
than  in  the  first  group 
of  cases  where  the  mus- 
cular coat  is  uninjured. 
In  most  cases  of  this 
group  we  find  the  growth 
has  spread  from  the 
mesenteric  glands.  It 
does  not  especially  affect 
the  solitarv  and  amnin- 


PiG.  104. — Small  Intestine  showing  Lymph - 
adenoma  of  Solitary  Glands  and  Peyer's 
Patches. 


ated       glands.       Severe 


(Royal  Coll.  of  Surg.  Mus.,  No.  2523  A.) 


diarrhoea  is  a  prominent 
symptom."  Dr.  Newton 
Pitt  has  collected  seven 
recorded  cases  iUustrat- 

ing  the  first  group  and  eleven  illustrating  the  second. 

In   the    first    group   of   cases  the  growth   is   apt    to    be 

scattered  irregularly   about   the   bowel   in    the  form  of  soft, 


SARCOMATA.  267 

whitish,  succulent  nodules,  or  plaques,  reaching  in  places  to 
ver}^  large  masses  of  new  growth. 

Intestinal  obstruction  is  very  rare.  Indeed,  in  only  one 
of  the  recorded  cases  ^  is  this  condition  mentioned. 

Dr.  Carrington  reports  an  instance  in  which  a  lympha- 
denomatous  mass  weighing  no  less  than  half  a  pound  occu- 
pied the  caecum,  and  yet  no  symptoms  of  obstruction  were 
produced,  nor,  indeed,  was  special  attention  directed  to  the 
abdomen  during  life.t 

So  far  as  the  clinical  manifestations  of  lymphadenoma 
of  the  bowel  are  concerned,  the  trouble  is  somewhat  more 
common  in  males  than  in  females. 

Most  of  the  patients  have  been  adults  between  twenty 
and  forty.  A  few  cases  have  been  met  with  in  children. 
The  extremes  of  age  in  the  recorded  cases  are  respectively 
four  and  fifty-four  years. 

The  general  symptoms  have  shown  much  variation. 
There  is  usually  distinct  impairment  of  health  with  wasting 
anoemia  and  diarrhoea. 

Digestive  disturbances  are  common,  associated  with 
colic,  distension  of  the  abdomen,  and  possibly  ascites. 
Enlargement  of  the  tonsils  has  been  noticed  in  some 
cases,  and  enlarged  glands  in  others.  Hypertrophy  of  the 
spleen  may  be  met  with,  and  masses  of  enlarged  mesenteric, 
or  retroperitoneal,  glands  may  be  detected.  Very  often  no 
definite  tumour  is  discovered.  In  not  a  few  of  the  cases 
there  have  been  no  abnormal  abdominal  symptoms.  The 
progress  of  the  cases  is  rapid,  and  death  is  very  apt  to 
occur  within  twelve  mouths  of  the  onset  of  the  mischief. 

7.  Sarcomata. — Sarcoma  of  the  intestine  is  less  common 
than  is  lymphadenoma,  the  relative  proportion  of  the  two 
neoplasms  being  given  by  some  authors  as  about  1  to  3. 

The  sarcoma  may  be  primary  or  secondary.  It  may  be 
spindle-celled  or  round- celled.  It  may  be  met  with  in  any 
part  of  the  alimentary  canal,  but— if  the  rectum  be  excluded 
— the  growth  is  much  more  common  in  the  small  intestine 
than  in  the  colon.     In  the  colon,  indeed,  it  is  very  rare. 

The  growth,  as  a  rule,  has  its  origin  in  the  submucous  tissue. 

It  may  appear  as  a  sessile  or  polypoid  tumour.  In  such 
case,  it  is  usuall}^  of  the  spindle-celled  type,  and  is  of  slow 
growth.  More  often  the  sarcoma  takes  the  form  of  a  diffuse 
infiltration  of  the  bowel,  the  orowth  in  such  case  being 
commonly  round-celled  (Fig.  105). 

*  Dr.  Coupland ;   Path.  Soc.  Trans.,  vol.  xxviii.,  p.  127. 
•j-  £rit.  Med.  Journ.,  vol.  ii.,  1883,  p.  773.     See  also  Ziemssen's  Encyclo- 
paedia of  Medicine,  vol.  xvi.,  p.  837. 


■268 


SARCOMATA. 


The  intestinal  canal  may  be  converted  by  the  diffused 
growth  into  a  rigid  tube.  The  lumen  of  the  affected  tube  is 
usually  dilated.  It  may,  however,  be  contracted,  although 
contraction  sufficient  to  cause  intestinal 
obstruction  is  quite  uncommon. 

Most  of  the  patients  have  been  between 
thirty  and  forty  years  of  age.  In  fourteen 
cases  collected  by  Madelung,'^  the  extremes 
of  age  were  respectively  four  years  and 
fifty-two  years. 

The  clinical  manifestations  are  hardly 
to  be  distinguished  from  those  which  attend 
lymphadenoma. 

There  are  malaise,  increasing  weakness, 
increasing  pallor  and  wasting,  irregularity 
of  the  bowels,  dyspepsia,  loss  of  appetite, 
flatulence,  mild  colic,  possibly  fever  and 
possibly  intestinal  obstruction.  A  definite 
tumour  is  often  to  be  made  out.  In  a  case 
of  sarcoma  of  the  duodenum  reported  by 
Dr.  Rolleston,t  the  symptoms  closely  re- 
sembled those  of  ulcer  of  the  stomach. 

The  progress  of  the  disease  is  rapid, 
and  death  may  be  expected  to  take  place 
within  nine  months. 

In  one  case,  the  patient  is  reported  to 
have  lived  for  one  year  and  nme  months. 

In  a  specimen  in  the  London  Hosj^ital 
Museum  is  shown  a  tumour  that  is  appar- 
ently a  primar}^  melanotic  growth  arising 
from  the  ileum.  So  far  as  I  can  ascertain, 
such  tumours  are  extremely  rare.  The  case 
from  which  the  specimen  is  taken  is  peculiar. 
The  patient,  a  woman,  died  of  an  intussus- 
ception, at  the  apex  of  w^hich  the  growth 
was  found.  She  had  a  suiall  lump  in  her 
groin  which  w^as  supposed  to  be  a  strangu- 
lated hernia.  It  was  cut  down  upon  and 
found  to  be  a  gland  affected  with  melanosis. 

It  would  appear  that  sarcomata  of  the 
rectum  are  very  often  of  the  melanotic 
type,  j 

*  Centralblatt  fiir  Chirurgie,  1892,  p.  617. 

t  Path.  Soc.  Trans.,  1892,  p.  67. 

J  See  cases  by  Heaton,  Path.  Soc.  Trans.,  1894,  p.  85;  Lange,  iN'ew  York 
Med.  Journ.,  1887,  p.  274 ;  and  cases  quoted  by  Cooper  and  Edwards  in  their 
work  on  Diseases  of  the  Rectum. 


Pi&.  105.  —  Lympho- 
sarcoma of  the  Ileum. 
impHcating  Peyer's 
Patches. 

This  specimen  may  per- 
liaps  more  properly  be 
called  a  Ijmpli adenoma. 

{Royal  Coll.  of  Surg.  Mus., 
No.  2523  B.) 


269 


CHAPTER   X. 

OBSTRUCTION   DUE   TO   THE    PRESSURE  OF  TUMOURS- 
ETC.,    EXTERNAL    TO    THE    BOWEL. 

Tumours  of  various  kinds  and  even  displaced  viscera  may 
press  upon  some  part  of  the  intestine  and  cause  thereby  an 
occkision  of  its  lumen. 

In  the  majority  of  the  cases  this  compression  has  been 
effected  by  a  tumour  having  origin  in  the  pelvis. 

Thus  the  bowel  may  be  compressed  by  a  retro  verted  or 
retroflexed  uterus,  especially  when  enlarged  by  pregnancy,* 
or  by  malignant  or  other  tumours  growing  from  the  uterus,t 
or  by  ovarian  tumours  of  any  kind.  J  The  last-named  variety 
of  growth  is  a  frequent  cause  of  obstruction  by  compression. 
Leichtenstern  has  found  instances  of  compression  of  the  gut  by 
a  large  vesical  calculus.  Mr.  Pye  gives  an  example  of  compres- 
sion due  to  a  large  abscess  situated  between  the  rectum  and  the 
uterus.§  Dr.  Hall  Davis  has  reported  a  very  interesting  case 
in  which  the  csecum  was  occluded  by  the  pressure  of  a  tumour 
due  to  tubal  pregnancy  of  the  right  side.||  Among  other 
causes  of  pressure  upon  the  gut  may  be  mentioned  subperi- 
toneal tumours,  tumours  of  the  mesentery  or  omentum,  various 
tumours  of  the  kidney,  psoas  abscesses  and  abscesses  about  the 
csecum,^  hydatid  cysts,"^"*  enlarged  or  movable  spleens.tt  The 
duodenum  especially  may  be  compressed  by  tumours  growing 

*  Journ.  cle  Med.  Chir.,  etc.  Bruxelles,  1867.  See  also  the  two  cases  detailed 
at  the  end  of  this  chapter. 

t  Mr.  Gay ;  Path.  Soc.  Trans.,  vol.  iii.,  p.  108. 

X  Le  Dentu;  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1879,  p.  661. 
Mr.  Heath  ;  Path.  Soc.  Trans.,  vol.  xvi.,  p.  107.  M.  Verneuil ;  Bull,  de  la  Soc. 
Anat.,  1870,  p.  411.  Cropf  ;  Annual  of  the  Universal  Med.  Sci.,  1893,  vol.  iii.,. 
C-5o;  and  Ricard  ;  Ibid.,  1892,  vol.  iii.,  C-61. 

§  Brit.  3Ied.  Journ.,  vol.  ii.,  1882,  p.  1152. 
Path.  Soc.  Trans.,  vol,  iv.,  p.  230. 

H  Cases  quoted  by  Leichtenstern,  loc.  cit.,  p.  573. 

**  Path.  Soc.  Trans.,  vol.  v.,  p.  302. 

ft  Case  quoted  by  Duchaussoy. 


270     COMPRESSION   DUE    TO    EXTERNAL    TUMOURS. 

from  the  pancreas,*  by  growths  arising  from  the  hver,  and  by 
masses  of  enlarged  glands  about  the  portal  vein.  Dr.  Baim- 
brigge  reports  a  case  of  obstruction  of  the  gut  brought  about 
by  pressure  indirectly  exercised  by  a  displaced  supplementary 
spleen,t  and  Dr.  Servier  quotes  an  instance  where  a  hyper- 
trophied  spleen  had  dragged  upon  the  pancreas  and  had 
displaced  it  so  that  it  had  compressed  some  coils  of  intestine 
that  had  found  their  way  beneath  it.  J  Rollet§  gives  an 
instance  of  compression  by  the  pedicle  of  a  movable  kidney, 
and,  lastly,  cases  have  been  reported  wdiere  a  piece  of  intestine 
has  been  engaged  and  compressed  between  the  ribs  and  the 
convexity  of  the  liver.  || 

With  regard  to  the  segment  of  the  intestine  involved  in 
these  cases,  the  rectum,  as  it  may  be  supposed,  is  the  part 
that  most  frequently  suffers.  This  is  owing  to  the  preponder- 
ance in  the  pelvis  of  tumours  capable  of  exercising  this 
particular  compression.  The  rectum,  moreover,  is  fixed  and 
lies  against  the  solid  wall  of  the  pelvis.  The  parts  that  are 
involved  next  in  frequency  after  the  rectum  are  the  sigmoid 
flexure  and  the  lower  ileum.  It  will  be  seen  that  the  sigmoid 
flexure  could  readily  be  compressed  by  a  pelvic  tumour,  and 
that  the  coils  of  small  intestine  that  most  constantly  occupy 
the  pelvis  belong  to  the  lower  ileum.  I  have  collected  22 
examples  of  this  form  of  compression  of  the  bowel,  which 
may  be  thus  divided  with  regard  to  the  matter  of  site : 
Rectum,  10  ;  colon,  6  ;  caecum,  1 ;  small  intestine,  5.  Leich- 
tenstern  gives  the  following  table  as  a  result  of  the  examina- 
tion of  a  large  number  of  cases  collected  by  himself : — 


Compression  of  the  rectum,  in 

.         .     60 

per  cent. 

jj 

sigmoid  flexure  and 

descending 

colon,  in 

.     12 

9) 

lower  ileum,  in 

.     10 

)j 

duodenum,  in    . 

.       7 

jy 

ascending  colon,  in 

.       6 

JJ 

middle  ileum,  in 

.       4 

J) 

transverse  colon,  in  . 

1 

It  win  be  seen  that  the  more  fixed  parts  of  the  bowel 
suffer  the  most,  and  that  the  more  mobile  parts,  such  as 
the  jejunum  and  transverse  colon,  are  practically  exempt 
from  this  form  of  obstruction. 

In  all  the  instances  that  I  have  collected  the  patients 
were  adults. 

*  Mr.  Nathan;  Med.  Times  and  Gazette,  vol.  ii.,  1870,  p.  238. 

t  Lonc'on  Med.  Gazette,  1846. 

X  De  I'Occlusion  Intestinale,  p.  47.     Liege,  1871. 

§  Path.  u.  Therp.  d.  bewegl  Niere,  1866. 

II  Cases  by  Lavater  and  Kellenberg,  quoted  \>y  Leichtenstem. 


VARIETIES.  271 

The  symptoms  of  obstruction  that  arise  in  these  cases 
show  considerable  variety.  In  no  less  than  twelve  out  of 
the  twenty-two  examples  above  alluded  to  the  compression 
led  to  acute  obstruction,  the  patient  dying  after  symptoms 
the  duration  of  which  A'aried  from  forty-eight  hours  to  nine  days. 

In  two  instances  the  symptoms  were  subacute,  the 
duration  being  in  each  case  eighteen  claj's.  In  the  re- 
maining eight  examples  the  obstruction  produced  was  of 
a  decidedly  chronic  character. 

The  acute  cases  depend  upon  sudden  compression  of 
the  gut  due  to  abrupt  change  of  position  in  the  tumour 
or  in  some  abnormally  arranged  viscus,  such  as  an  unduly 
movable  spleen  or  kidney.  Or  they  may  be  due  to  kinking 
of  the  intestine,  or  to  abrupt  bending  of  the  more  mobile 
part  of  the  bowel  above  that  fixed  by  the  timiour,  or  to 
the  engagement  of  a  loop  of  intestine  beneath  the  mass 
or  between  it  and  the  pelvic  or  abdominal  walls.  The 
acuteness  of  the  case  appears  to  have  nothing  to  do  with 
the  segment  of  the  boAvel  involved,  but  to  depend  solely 
upon  the  abruptness  of  the  occlusion.  Many  of  the  more 
rapidly  fatal  cases,  cases  ending  in  death  on  the  fourth, 
sixth,  or  seventh  day,  have  depended  upon  sudden  occlusion 
of  the  rectum  or  of  the  lower  part  of  the  colon.  The  case 
alluded  to  above  as  fatal  in  forty-eight  hours  was  Dr. 
Baimbrigge's  case  of  compression  by  a  displaced  spleen. 
The  part  of  intestine  involved  was  the  colon. 

The  symptoms  that  appear  in  these  cases  are  simply 
those  of  acute  obstruction.  There  is  less  pain  and  less 
collapse  than  in  instances  of  strangulation  by  bands,  and 
the  whole  progress  of  the  malady  is  less  violent ;  but  the 
points  of  ditierence  are  not  sufficiently  accentuated  to  render 
a  diagnosis  certain.  In  many  instances  the  tumour  has 
been  felt,  and  the  nature  of  the  case  has  been  from  the 
first  evident  ;  but  in  other  examples  the  diagnosis  has 
been  actually  complicated  by  the  presence  of  the  tumour. 
A  good  instance  of  the  latter  condition  is  afforded  by  Dr. 
Hall  Davis's  case  of  tubal  pregnancy.  The  patient  was  aged 
thirty-two,  and  was  seized  with  symptoms  of  acute  intes- 
tinal obstruction  that  ended  in  death  on  the  ninth  day.  A 
fixed  and  tender  tumour  could  be  felt  in  the  right  iliac  fossa, 
vaginal  examination  revealed  nothing  abnormal,  and  "  all 
certain  signs  of  pregnancy  were  absent."  The  tumour 
depended  upon  a  tubal  pregnancy,  and  had  occluded  the 
csecum  by  pressure. 

The  following  interesting  case,  reported  by  Mr.  Colby,* 

*  £rit.  Med.  Journ.,  March  26,  1S98. 


272     COMPRESSION  DUE    TO   EXTERNAL    TUMOURS. 

provides  a  good  example  of  this  type  of  intestinal  obstruc- 
tion : — 

A  boy,  aged  seven  years,  was  seized  on  February  8tli  with  sudden 
pain  in  the  abdomen,  which  was  severe  and  lasted  three  hours  On 
February  9th  he  had  a  similar  attack.  On  February  11th  some  calomel 
was  given,  but  was  vomited.  On  February  12th  two  olive  oil  injec- 
tions were  given,  with  no  result.  On  the  evening  of  the  same  day  a 
castor-oil  and  glycerine  enema  was  given,  and  produced  only  a  few  hard 
lumps.     This  injection  was  rejieated  on  February  13th. 

On  February  16th  vomiting  set  in.  The  vomiting  was  "faecal." 
When  admitted  into  the  hospital  at  5  p.m.  on  February  16th  he  had 
the  facial  appearance  of  abdominal  trouble,  with  a  quick  pulse,  and  a 
dirty  but  moist  tongue.  The  abdomen  was  flaccid  and  not  distended. 
Peristaltic  intestinal  movements  were  everywhere  visible.  Per  rectum 
a  swelling  was  detected,  projecting  into  the  bowel.  This  swelling  so 
much  resembled  an  intussusception  that  water  was  injected  by  means 
of  a  siphon  :  this  injection  was  followed  by  the  disappearance  of  the 
rectal  swelling.  The  patient  was  seen  again  at  10  p.m.,  when  the  rectal 
lump  had  returned,  so  the  boy  was  put  under  an  anaesthetic ;  it  was 
now  more  obvious  that  the  swelling  felt  in  the  rectum  was  outside  the 
bowel.  Consequently,  the  abdomen  was  opened  in  the  middle  line 
below  the  umbilicus.  On  inserting  the  fingers  through  the  opening 
thus  made  an  elastic  swelling  of  the  size  of  a  small  cocoa-nut  was 
brought  out  of  the  wound.  This  proved  to  be  a  cyst  in  the  mesentery 
of  the  small  gut.  The  cyst  had  compressed  a  loop  of  small  intestine, 
which  was  closely  united  to  the  cyst  wall  and  flattened  out  against  it. 
An  attempt  Avas  made  to  dissect  out  the  cyst,  but  was  not  persisted  in, 
and  as  much  as  possible  of  the  wall  of  the  cyst  was  removed.  His 
recovery  was  uneventful. 

The  cyst  wall  when  distended  was  mottled  on  the  surface  like  a 
crumpet,  and  microscopically  was  composed  of  fibro-cellular  tissue, 
with  a  large  quantity  of  unstriped  muscle.  The  contents  measured  ten 
ounces  of  a  pale  pink  fluid,  whose  specific  gravity  Avas  1023,  and 
contained  a  large  quantity  of  albumin  and  cholesterin. 

In  some  of  the  cases  there  had  been  no  evidence  of 
intestinal  trouble  previous  to  the  final  attack. 

In  certain  of  the  chronic  cases  the  symptoms  were  pre- 
cisely like  those  of  stricture  of  the  intestine,  the  pro- 
gress of  the  case  being  marked  by  paroxysmal  attacks 
from  time  to  time.  In  other  instances  there  was  simply 
an  increasing  constipation  that  occasioned  no  great  amount 
of  disturbance  until  it  became  absolute,  and,  after  resisting 
all  attempts  at  relief,  ended  in  death. 

In  some  of  the  chronic  cases,  it  would  appear  that  the 
production  of  the  obstruction  symptoms  is  a  little  complex. 

As  examples  of  this,  I  would  cite  the  two  following  cases, 
which  have  occurred  to  me  in  private  practice.  One  was  that 
of  a  lady  of  forty-one,  who  had  been  in  bed  for  two  months 
with  symptoms  of  mild  chronic  intestinal  obstruction.  She 
had  had  six  children ;  menstruation  was  regular.  She  was 
thin,  and  the  abdominal  wall  was  lax  and  attenuated.     She 


VARIETIES.  273 

was  in  no  way  neurotic.  Her  troubles  had  followed  upon  an 
indefinite  condition  of  ill-health,  and  had  been  ushered  in  with 
a  violent  attack  of  pain  in  the  pelvis.  The  bowels  were  very 
confined,  scybala  were  passed,  there  were  nausea  and  loss  of 
appetite,  and  an  occasional  rise  of  temperature  towards  the 
latter  end  of  the  case.  There  was  some  flatulent  distension  of 
the  abdomen,  and  visible  coils  of  bowel  were  to  be  seen  in 
movement.  These  movements  were  attended  by  colic,  which 
was  more  or  less  persistent,  but  never  severe.  Menstru- 
ation was  attended  with  considerable  pain  in  the  left  side 
of  the  pelvis.  The  symptoms  sugg-es ted  some  partial  occlusion 
of  the  bowel,  due  possibly  to  a  stricture.  This  was  emphasised 
by  the  fact  that  the  rectum  was  ballooned.  The  patient  was 
not  comfortable  when  lying  down.  As  all  medical  measures 
had  failed,  I  carried  out  an  exploratory  incision.  The  dis- 
tended coil  seen  in  movement  was  the  sigmoid  flexure.  It  was 
full  of  gas,  but  its  walls  were  not  hypertrophied.  The  colon, 
and  especially  the  descending  colon,  contained  a  large 
quantity  of  hard  scybala.  The  obstruction  was  due  to  the 
retroflexion  of  an  otherwise  normal  uterus.  The  fundus  fell 
back  upon  the  bowel  and  compressed  it  against  the  pelvic 
wall.  It  was  not  possible  to  introduce  the  little  finger  between 
the  fundus  of  the  uterus  and  the  pelvic  wall.  The  uterus 
could  be  easily  lifted  up,  but  when  pushed  back  it  fell  upon 
the  bowel  like  a  closing  valve. 

The  bowel  wall  showed  no  contraction  in  any  part,  and 
was  perfectly  normal.  The  left  ovary  was  prolapsed.  The 
course  of  events  in  such  a  case  as  this  was  probably  as 
follows:  The  patient  is  out  of  health,  the  bowels  become  con- 
stipated, and  gas  and  fasces  collect  in  the  sigmoid  flexure. 
The  distended  coil  very  readily  adds  to  the  bend  in  the  retro- 
flexed  uterus,  and  the  gut  becomes  pressed  upon.  As  the 
bowel  remains  unrelieved,  that  pressure  does  not  become 
lessened.  The  ovary  is  prolapsed  and  may  be  made  the 
centre  of  reflex  nervous  disturbances.  That  there  is  consider- 
able local  nerve  disorder  is  shown  by  the  ballooned  rectum. 
The  constipation  may  have  been  largely  of  reflex  origin,  and 
the  displaced  uterus  may  well  have  inhibited  the  act  of 
defalcation. 

The  fundus  of  the  uterus  was  felt  per  rectum  before 
operation,  but  it  could  not  be  assumed  that  the  displacement 
alone  was  the  cause  of  the  intestinal  disturbance.  When  the 
parts  were  viewed  from  within  the  abdomen,  the  manner  in 
which  the  prominent  uterine  fundus  wedged  the  bowel  against 
the  pelvic  wall  was  very  emphatic,  and  there  is  no  doubt  that 
such  obstruction  as  this  induced  was  intensified  by  abiding 
s 


274      COMPRESSION   DUE    TO    EXTERNAL    TUMOURS. 

flatulent  distension  of  the  sigmoid  flexure  and  a  certain  ill- 
defined  disturbance  of  the  nerve  apparatus  of  the  parts 
concerned. 

In  the  second  case,  the  patient  was  younger,  was  unmar- 
ried, and  was  very  neurotic.  Her  bowel  troubles  had  followed 
a  severe  attack  of  influenza.  When  I  saw  her,  her  symptoms 
of  obstruction  had  existed  for  uver  three  months,  the  abdomen 
Avas  greatly  distended:  there  was  continued  colic  and  occa- 
sional vomiting  ;  visible  coils  of  intestine  in  movement  were 
apparent.  At  no  time  could  her  symptoms  be  said  to  have 
been  severe,  although  she  was  conflned  to  bed. 

On  opening  the  abdomen,  the  distension  was  found  to  be 
in  the  main  limited  to  the  sigmoid  flexure.  On  following  the 
bowel  down  towards  the  anus,  it  was  seen  to  be  jammed  between 
the  pelvic  wall  and  a  retroflexed,  but  otherwise  normal,  uterus. 
The  obstacle  offered  by  the  uterus  was  most  definite,  and  its 
valve-like  partial  occlusion  of  the  bowel  was  readily  demon- 
strated. The  intestine  could  hardly  be  said  to  be  in  an}^ 
appreciable  way  hypertrophiecl,  although,  as  its  walls  did  not 
appear  to  be  as  attenuated  as  the  distension  of  the  gut  would 
suppose,  some  muscular  increase  must  have  been  present.  In 
this  case  also  there  was  ballooning  of  the  rectum.  There  was 
nothing  abnormal  in  the  condition  or  situation  of  the  ovaries. 
As  the  bowel  had  been  so  long  distended,  I  made  a  pin-hole 
stoma  in  the  sigmoid  flexure.  This  prevented  the  accumula- 
tion of  gas  and  gave  the  long  distended  bowel  a  period  of  rest. 

At  the  end  of  two  months  I  closed  the  little  opening  by  a 
second  operation. 

In  this  case  also  there  appeared  to  be  a  considerable 
degree  of  nerve  disturbance,  in  addition  to,  and  possibly 
dependent  upon,  the  wedging  down  of  the  uterus. 

In  connection  with  the  subject  of  obstruction  due  to  the 
pressure  of  tumours  outside  the  bowel,  reference  maybe  made 
to  the  account  which  has  been  already  given  (page  88)  of 
adhesions  which  produce  symptoms  of  intestinal  obstruction 
by  compressing  the  gut. 


275 


CHAPTER    XL 

F.'ECAL    ACCUMULATION. 

It  is  not  uncommon  for  the  bowel  to  become  blocked  by 
an  accumulation  of  fsecal  matter  within  its  lumen. 

It  will  be  obvious  that  this  form  of  obstruction  must  be 
practically  limited  to  the  colon.  If  it  involve  the  small 
intestine  it  must  be  by  extension  of  the  accumulation  from 
the  colon.  It  cannot  occur  primarily  in  the  small  intestine. 
The  blocking  of  the  lesser  bowel  by  foreign  substances 
which  have  been  swallowed,  or  by  masses  of  utterly  indi- 
gestible matter,  cannot  be  considered  to  come  under  the 
present  category. 

The  colon  being  the  part  of  the  bowel  involved  in 
obstruction  due  to  faecal  accumulation  it  may  be  further 
assumed  that  the  blocking  of  the  gut  will  most  usually 
concern  its  lower  or  terminal  parts. 

Accumulations  of  faeces  are  most  common  in  the  rectum 
and  sigmoid  flexure,  and  then  in  the  caecum.  Masses  of 
fseces  may  block  the  colon  at  any  point,  and  more  particularly 
at  the  flexures  of  the  bowel.  Still  the  three  common  sites 
of  the  accumulation  are  those  just  named. 

The  accumulation  in  the  colon  may  assume  the  form  of  a 
more  or  less  isolated  nodule  or  mass. 

Thus  a  considerable  lump  may  be  found  in  the  caecum  or 
sigmoid  flexure,  and  the  rest  of  the  colon  be  comparatively 
clear  of  any  gross  accumulation.  An  isolated  lump  ma}' 
even  persist  after  free  purgation. 

On  the  other  hand  the  accunudation  may  assume  the 
form  of  several  isolated  fajcal  masses.  One  of  these  ma}' 
occupy  the  ctecum,  another  the  transverse  colon,  and 
possibly  a  third  the  sigmoid  flexure.  The  bowel  between 
these  masses  may  appear  to  be  fairly  clear. 

Finally,  the  accunmlation  may  take  the  form  of  a  steady 


276  F^GAL    ACCUMULATION. 

tilling  up  of  the  colon  from  the  rectum  or  sigmoid  flexure 
upwards.  After  the  sigmoid  tlexure  has  been  filled  the 
descending  colon  becomes  blocked  with  faices,  then  the 
transverse  colon  is  occupied,  until  at  last  the  csecum  is 
reached.  Cases  have  been  recorded  in  which  the  entire 
colon  has  been  occupied  from  one  extremity  to  another  by 
an  incredible  accumulation  of  fascal  matter. 

The  isolated  masses  are  composed  of  comparatively  hard 
fiecal  lumps,  Avhile  in  the  general  filling  up  of  the  colon 
from  below  the  collected  fasces  are  of  a  softer  character. 
In  the  majority  of  the  instances  of  blocking  of  the  whole 
colon  there  is  some  mechanical  obstruction  towards  the 
rectal  end  of  the  gut.  This  may  be  due  to  distortion  of  the 
sigmoid  flexure  dependent  upon  the  overloading  of  that  coil. 
Such  a  case  would  come  under  the  present  category. 

It  is  obvious,  therefore,  that  the  size  of  the  faecal  mass 
may  vary  from  a  small  lump  of  the  dimensions  of  a  hen's 
Qgg  to  a  huge  column  of  excrementitious  matter  which  may 
engage  the  whole  of  an  enormously  distended  colon. 

The  sacculi  of  the  large  intestine  lend  themselves  to 
the  lodg'ment  of  faecal  matters,  and  the  harder  of  the 
masses  met  with  in  the  bowel  are  moulded  within  these 
sacculi. 

It  is  curious  and  noteworthy  that  retained  faeces  tend  to 
become  inspissated  and  hardened. 

Some  masses  which  have  been  long  retained  seem  to  have 
parted  with  ■  all  their  moisture  and  to  have  the  consistence 
almost  of  dry  mortar. 

In  the  diarrhoea  which  often  follows  the  ridding  of  the 
colon  of  a  fsecal  accumulation  scybala  of  intense  hardness 
and  dryness  may  not  infrequently  be  found  among  the 
liquid  stools. 

The  causes  of  ftecal  accumulation  are  the  causes  of  chrome 
constipation,  and  into  the  etiology  of  this  common  aftection 
it  is  unnecessary  to  enter  in  this  work. 

It  will  suffice  to  allude  to  certain  of  the  factors  which 
bring  about  this  loading  or  blocking  of  the  bowel. 

1.  In  many  cases  there  is  evidence  of  diminished  expulsive 
power,  or  of  defective  innervation  of  the  bowel. 

This  weakness  would  appear  in  some  cases  to  be  congenital. 
It  is  more  often  acquired.  It  is  illustrated  by  the  constipation 
which  may  attend  certain  exhausting  diseases  and  certain 
injuries  and  afl'ections  of  the  brain  and  spinal  cord.  It  is 
concerned,  possibly,  to  some  extent,  with  the  constipation  of 
the  insane  and  the  neurotic. 

In  association  with  this  factor  in  the  etiology   nuist  be 


ITS    CAUSES.  277 

noticed  the  effect  of  weak  abdominal  muscles,  of  lack  of 
exercise  on  the  patient's  part,  of  damage  to  the  mnscular 
apparatus  of  the  bowel  from  long  continued  inflammation  of 
its  walls,  and  the  result  of  the  long  over-use  of  aperients. 

2.  In  the  second  place  there  may  appear  to  be  some 
inhiljition  of  the  act  of  defecation.  This  is  illustrated  by  the 
constipation  attending  painful  piles,  fissure  of  the  anus, 
operations  upon  the  anus,  painful  bladder  affections  and 
the  like. 

ICxamples  are  also  provided  by  the  intestinal  lethargy 
Avhichis  often  associated  with  a  chronically  diseased  vermiform 
appendix  or  an  inflamed  ovary,  and  which  disappears  in  a 
marvellous  inanner  when  the  irritatinof  organs  are  removed. 

The  obstruction  of  the  bowels  which  may  attend  a  local 
and  quite  slight  degree  of  peritonitis,  or  a  slight  injury  to  the 
serous  membrane  itself,  probably  belongs  to  this  category. 

It  is  noteworthy  how,  in  certain  of  these  cases,  opium  acts 
as  an  aperient. 

3.  In  a  third  series  of  examples  the  trouble  appears  to 
depend  less  upon  the  condition  of  the  bowel  itself  and  more 
upon  the  state  of  its  contents. 

Under  this  heading  must  be  found  the  constipation  which 
attends  chronic  dyspepsia,  the  bolting  of  food,  the  eating  of 
food  at  irregular  hours,  and  the  consumption  of  masses  of 
indigestible  matter.  In  certain  instances  the  actual  articles 
of  food  eaten  by  the  patient  cannot  be  classed  as  indigestible, 
but  they  are  unsuitecl  to  the  particular  individual.  For 
example,  one  has  often  noticed  that  in  adults  the  persistence 
in  a  milk  diet  may  lead  to  the  formation  of  the  densest  of 
scybala 

In  some  persons  constipation  appears  to  be  largely  due  to 
the  small  quantity  of  fluid  taken  daily  with  the  food. 

4.  Finally,  it  is  possible  roughly  to  distinguish  a  class  of 
cases  in  which  some  anatomical  disposition  or  some  slight 
pathological  lesion  would  appear  to  be  a  prominent  factor  in 
the  production  of  the  accumulation. 

The  colon  is  found  to  be  unduly  long  or  portions  of  it  are 
unduly  prominent.  Thus  the  ctecum  may  be  found  to  form 
a  large  and  elongated  pouch,  which  may  hang  listlessly  into 
the  pelvis,  or  be  lying  on  the  pelvic  floor.  The  sigmoid  flexure 
may  be  long  and  pendulous,  and  may  so  nearly  conform  to 
the  outline  of  a  capital  omega  that  its  two  extremities  are  in 
actual  contact.  Nearly  the  whole  of  the  free  part  of  the  loop 
may  be  lying  in  the  pelvis. 

The  transverse  colon  may  be  elongated  and  distorted ;  it 
may  assume  a  V-liko  bend,  and  the  centre  of-  the  loop  may 


278  FJ^CAL    ACCUMULATION. 

be  on  a  level  with  the  symphysis  pubis.  In  cases  of  relaps- 
ing perityphlitis  associated  with  marked  constipation  I  have 
several  times  seen  the  transverse  colon  present  at  the  wound 
made  in  the  right  iliac  fossa  for  the  purpose  of  removing  the 
appendix. 

In  the  cases  of  deformity  which  have  just  been  mentioned, 
it  is  impossible  to  say  which  condition  is  antecedent  to  the 
other,  the  constipation  or  the  anomaly  in  the  bowel.  It  is 
easy  to  understand  that  long  continued  over-loading  of  the 
colon  may  lead  to  such  changes  in  the  large  intestine  as  have 
been  just  described. 

In  other  examples,  the  constipation  is  associated  with  some 
congenital  narrowing  of  the  colon,  short  of  a  state  of  actual 
stricture.  Su^di  cases  have  been  alluded  to  in  the  section  on 
congenital  deformities  of  the  bowel  (page  250).  The  sigmoid 
flexure  in  other  instances  may  be  unduly  short,  or  the  sigmoid 
mesocolon  may  be  scanty  and  very  much  over-loaded  with 
fat. 

There  may  be  a  contraction  or  shrinking  of  the  sigmoid 
mesocolon  whereby  the  free  movement  of  that  coil  is 
hindered.  A  peritoneal  band  may  be  associated  with  the 
colon  in  such  a  way  as  to  inhibit  a  normal  peristalsis. 
Fig.  30  shows  a  broad  membranous  band  connected  with  the 
sigmoid  flexure,  which  may  have  had  such  effect. 

From  the  present  category  are  excluded  the  frequent  cases 
in  which  the  ftecal  accumulation  is  dependent  upon  the 
pressure  of  a  tumour  or  a  retroflexed  utenis,  or  upon  the 
impediment  offered  by  an  enlarged  prostate,  or  by  moderate 
adhesions,  and  the  like. 

An  account  of  the  tumour  formed  b}^  a  mass  of  ac- 
cumulated faeces  is  given  in  the  clinical  section  of  this  book. 

The  amount  of  the  accumidation  may,  as  already  stated, 
vary  from  a  few  isolated  and  not  unduly  large  masses  to  a 
collection  which  may  occupy  the  whole  of  the  colon,  from 
the  anus  to  the  ileo-caical  valve. 

We  read  of  cases  Avhere  after  death  a  "  bucketful "  of 
fbeces  was  removed  from  the  colon.  Lemazurier  mentions  a 
case  where  a  mass  of  fiscal  matter  weighing  thirteen  pounds 
was  removed  from  the  rectum,  In*an  instance  reported  by 
Renauldin  it  is  said  that  at  the  time  of  the  patient's  death 
sixty  pounds  of  fa3ces  had  accumulated  in  the  colon. 
Leichtenstern  in  his  conunents  upon  this  case  wisely  remarks 
that  we  may  entertain  "  legitimate  doubts  "  of  its  authenticity. 

In  cases  of  extensive  accumulations  the  colon  may  become 
of  enormous  size.  The  caecum  in  such  instances  has  been 
described  as  as  larye  as  an  adult's  head,  the  sicfuioid  flexure 


ITS    EFFECTS.  279 

or  the  transverse  colon  may  appear  to  occupy  the  greater 
part  of  the  abdomen,  while  the  diameter  of  the  distended 
bowel  may  attain  to  six,  eight,  or  ten  inches.  I  am  rather 
disposed  to  think  that  these  cases  of  extensive  and  enormous 
distension  of  the  colon  are  usually  associated  with  some 
mechanical  impediment  to  the  passage  of  feces,  and  are  not 
common  in  connection  with  a  mere  passive  accunuilation  of 
fffical  matter. 

This  point  has  been  alluded  to  in  dealing  with  the  subject 
of  idiopathic  dilatation  of  the  colon  (page  242). 

As  an  example,  however,  of  a  case  in  which  it  woidd 
appear  that  the  accumulation  was  the  outcome  of  mere 
constipation,  I  may  quote  the  following. 

Dr.  Little^  reports  the  case  of  an  idiot,  aged  thirty-four, 
who  died  of  the  effects  of  long-continued  constipation.  He 
had  possessed  an  enormous  appetite,  and  had  been  in  the 
habit  of  eating  great  quantities  of  indigestible  food. 

-  At  the  autopsy  the  transverse  colon  was  found  to  be 
six  inches  in  diameter,  while  the  descending  colon  and 
sigmoid  flexure  formed  a  huge  pouch  measuring  twenty 
inches  by  twelve  inches  The  walls  of  the  sigmoid  flexure 
are  said  to  have  been  from  one-third  to  one-half  of  an  inch 
in  thickness. 

In  the  mucous  membrane  above  the  obstructed  segment 
certain  ulcers  may  form,  known  as  stercoral  ulcers.  These 
are  due  partl}^  to  gangrene  of  t'ne  mucous  membrane  from 
pressure,  and  partly  to  the  irritating  and  chemical  effects  of 
the  long  retained  and  altered  faecal  masses.  They  generally 
appear  in  the  form  of  sloughs  of  the  mucous  membrane, 
which  may  extend  until  ulcers  of  large  size  are  produced. 
There  may  be  many  of  such  ulcers.  They  are  most  com- 
monly met  with  in  the  c;ecum,  in  the  lower  part  of  the 
ileum,  and  in  the  sigmoid  flexure.  The  largest  and  most 
numerous  are  met  with  in  the  Ccecum. 

They  may  lead  to  acute  peritonitis  by  abrupt  perforation. 
When  the  perforation  is  slow  and  gradual,  a  form  of  localised 
and  subacute  peritonitis  may  be  produced.  The  slow  per- 
foration may  lead  to  an  abscess,  to  a  comnmnication  between 
the  colon  and  another  part  of  the  intestine,  or  to  a  vesico- 
colic  fistula.  It  may  be  the  cause  of  numerous  and  complex 
adhesions,  which  may  deform  the  bowel :  it  may  lead  to  a 
form  of  pelvic  cellulitis,  which  has  been  more  than  once 
nu'staken  for  a  pelvic  sarcoma ;  it  may  cause  a  firm  attach- 
ment between  the  colon  and  some  other  organ  or  peritoneal 
surface. 

*  Piitli.  iSoc.  Tians.,  vol.  iii.,  p.  106. 


280  F2EGAL    ACCUMULATION. 

It  has  been  already  stated  that  the  stercoral  ulcer  m 
process  of  cicatrisation  may  lead  to  stricture  of  the  large 
intestine. 

Excellent  examples  of  the  perforation  or  giving  way  ot 
the  bowel  at  the  seat  of  a  stercoral  ulcer,  associated 
with  fsecal  accumulation,  are  given  by  Southam"^  and 
Berry,  t 

In  certain  recorded  examples  the  over- distended  bowel 
has  become  ruptured  and  has  been  rent  open.  It  is  not, 
however,  quite  demonstrated  that  such  rupture  may  take 
place  independently  of  any  ulceration  of  the  gut.  As  a 
rule,  the  bowel  wall  has  been  found  to  be  ulcerated,  and,  in 
places,  gangrenous. 

Ileus  Paralyticus. — It  will  here  be  convenient  to  allude  to 
the  condition  known  to  older  writers  as  "  ileus  paralyticus." 
This  term  is  applied  to  the  condition  of  acute  ob- 
struction, or  of  acute  peritoneal  disturbance  which  not 
infrequently  marks  the  close  of  a  case  of  fsecal  accumu- 
lation. 

It  is  assumed  that  the  primary  cause  of  l?ecal  accumu- 
lation is  an  insufficiency  in  the  forces  which  move  the 
intestinal  contents  forwards.  If  this  lack  of  power  advances 
to  a  state  of  absolute  paralysis  of  a  segment  of  the  bowel, 
then  it  is  said  there  arise  symptoms  of  an  acute  character, 
associated  with  collapse,  intense  pain,  increased  tympanites, 
and  continued  vomiting. 

The  sole  pathology  of  ileus  paralyticus  is  summed  up  in 
the  assumption  that  a  portion  of  the  bowel  has  become 
incapable  of  peristaltic  movements,  and  as  a  residt  of  this 
acute  symptoms  follow. 

It  is  stated  that  ileus  paralyticus  could  affect  both  the 
small  and  the  large  intestine. 

I  venture  to  think  that  ileus  paralyticus,  as  described 
in  the  text-books  and  in  the  previous  edition  of  this  work, 
has  no  clinical  existence. 

It  has — so  far  as  I  am  aware — never  been  shown  that 
complete  paralysis  of  a  segment  of  the  bowel  can  alon^^ 
lead  to  symptoms  of  acute  intestinal  obstruction  which  end 
rapidly  in  death. 

It  is  claimed  that  the  persistence  of  s3nnptoms  after  the 
successful  reduction  of  a  strangulated  hernia,  or  the  success- 
ful restoration  of  a  volvulus  of  the  colon,  are  examples  of 
this ;  but,  so  far  as  my  experience  goes,  the  persistence  of 

*  £rit.  Med.  Jovrn.,  1895,  vol.  i.,  p.  254. 
t  llnd.,  1891  vol.  i.,  p.  301. 


ILEUS    PABALYTIGUS.  281 

symptoms  under  the  conditions  named  is  due  to  a  definite 
peritonitis. 

The  symptoms  in  question  are  increasing  feebleness  pass- 
ing into  collapse,  undiminished  tympanitic  distension,  in- 
creasing vomiting,  and  usually,  but  by  no  means  necessarily, 
a  continued  inability  of  the  bowels  to  act. 

How  often  it  is  that  the  symptoms  persist  and  rapid 
death  follows  the  liberation  of  a  coil  of  intestine  strangulated 
by  a  band.  Such  death,  however,  is  due  to  peritoneal 
infection  or  septic;emia,  and  not  to  ileus  paralyticus.  Those, 
however,  who  still  claim  that  ileus  paralyticus  exists  would 
maintain  that  the  persistence  of  the  symptoms  and  the  final 
dissolution  of  the  patient  are  due  to  the  fact  that  the 
damaged  coil  of  intestine  remains  paralysed. 

Now  and  then  among  the  records  of  abdominal  opera- 
tions one  notices  the  report  that  the  patient  died  of 
"paralytic  distension  of  the  bowel."  In  such  cases  the 
following  symptoms  have  developed  within  a  few  days  or 
perhaps  a  few  hours  of  the  operation.  The  abdomen 
becomes  distended,  there  is  obstinate  vomitinsj-,  there  are 
increasiog  feebleness  and  failure  of  the  pulse,  and  possibly 
complete  constipation.  No  measures  which  are  adopted  to 
relieve  the  bowel  afford  relief,  the  tympanites  remains  and 
probably  increases,  the  eyes  become  sunken  and  the  tongue 
dry,  and  as  the  pulse  increases  in  rapidity  and  threadiness 
the  patient  begins  gradually  to  sink.  He  dies  collapsed, 
like  a  poisoned  man.  There  may  have  been  but  little  pain, 
and  no  great  degree  ot  tenderness,  and  no  necessary  rise  of 
temperature,  but  such  a  patient  does  not  die  of  ileus 
paralyticus.  The  bowel  may  be  " paralytically  fixed"  in 
the  abdou:ien,  but  the  cause  of  such  cessation  of  peristalsis 
is  peritonitis  and  the  septica^mic  condition  which  creeps 
along  with  it.  I  have  never  met  with  an  example  of  such 
a  case  as  this  in  which  a  diffused  peritonitis  was  not  found 
after  death.  The  surgeon  is  very  loth  to  own  to  any 
septic  element  in  the  case,  and  there  is  no  doubt  that 
'•■  ileus  paralyticus,"  "  paralytic  distension  of  the  bowel," 
"  traumatic  paresis  of  the  bowel,"  and  the  like  have  salved 
many  surgical  consciences. 

The  fact  that  the  patient  may  recover  from  mild  phases 
of  post-operation  peritonitis  cannot  be  allowed  to  furnish 
an  argument  in  support  of  ileus  paralyticus. 

As  an  example  of  this  inore  fortunate  condition  I  may 
quote  the  following  case. 

I  removed  the  appendix  of  a  man  aged  thirty-four  for 
relapsing  perityphlitis.      The  operation  was  of  the  simplest 


282  Fungal  ag cumulation. 

possible  cliaracter,  but  it  was  done  under  somewhat  dis- 
advantageous conditions.  On  the  third  day  after  the  opera- 
tion the  patient,  who  had  so  far  not  made  a  good  recovery, 
began  to  vomit.  The  abdomen  was  distended,  especially  in 
the  epigastric  region.  A  great  transverse  coil,  absolutely 
tympanitic,  aj)peared  to  occupy  that  district.  He  vomited 
everything  he  took.  The  abdomen  was  the  seat  of  dis- 
comfort, but  not  of  pain.  It  could  hardly  be  called  tender. 
All  food  by  the  mouth  was  discontinued,  and  then  a 
distressing  hiccough  began.  The  temperature  remained 
normal,  the  pulse  about  100.  The  bowels  responded  to  a 
salt  enema.  The  patient  had  had  morphia  for  two  days 
after  the  operation,  but  no  morphia  was  given  on  or  after 
the  third  day.  He  was  treated  by  rectal  feeding  and  by 
hypodermic  injections  of  strychnia.  The  hiccough,  with 
occasional  sickness,  continued  for  nearly  fourteen  days, 
coming  on  in  paroxysms.  The  abdomen  remained  distended 
as  it  was  at  the  onset  of  the  symptoms,  but  was  free  from 
tenderness  and  from  anything  more  than  discomfort.  The 
patient  made  a  perfect  recovery.  I  have  no  doubt  whatever 
that  these  protracted  symptoms  were  due  to  a  phase  of 
peritonitis. 

As  an  argument  in  favour  of  the  existence  of  ileus 
paralyticus  it  has  been  pointed  out  that  experiments  upon 
aniinals  show  that  a  coil  of  bowel  which  is  enormously 
distended  with  gas  will  not  respond  to  the  strongest  elec- 
trical current,  and,  further,  that,  if  the  distension  be  Jong 
maintained,  the  gut  will  scarcely  recover  its  muscular 
power. 

It  is  quite  possible  that  this  may  be  true  of  the  intestine 
of  man,  but  it  has  not  been  shown  that  such  paralysis  can 
lead  to  the  particular  train  of  acute  symptoms  which  are 
considered  to  indicate  ileus  paralj^ticus.  The  greatly  dis- 
tended bowel  is  apt  to  be  already  ulcerated,  it  is  disposed 
to  become  perforated  and  even  gangrenous,  and  in  con- 
ditions short  of  these  extreme  lesions  it  is  probable  that 
its  damaged  wall  will  easily  allow  of  the  escape  of  bacteria 
from  the  lumen  of  the  gut. 

It  is  needless  to  say  that  in  cases  of  f;eca!  accumulation 
the  bowel  may  become  mechanically  blocked  with  fajcal 
matter,  just  as  a  small  drain-pipe  may  becoinc  blocked  by 
an  accunudation  of  solid  sul>stances  which  have  passed  into 
it.  In  most  cases,  even  in  large  accumulations,  flatus  will 
continue  to  pass,  and  occasionally  a  little  f;ecal  fluid,  the 
result  of  catarrh  in  the  segment  of  the  bowel  above  the 
block.     The  bowel   at   the   seat   of  the   accumulation  is  no 


JL7^r.>'    PAKALYTICTTS.  283 

doubt  incapable  of  action,  and  is  inert  and  practically 
paralysed.  The  S3nnptoms,  however,  which  attend  this  con- 
dition are  not  those  ascribed  to  ileus  paralyticus.  They  are 
the  symptoms  of  chronic  obstruction.  If  the  loaded  bowel 
becomes  actually  kinked  or  twisted  upon  itself,  then  the 
phenomena  of  acute  obstruction  are  produced,  but  to  such 
phenomena  the  name  ileus  paralyticus  cannot  be  applied. 


PART    II. 

THE    CLINICAL    MANIFESTATIONS. 


CHAPTER  I. 

THE    CLINICAL    VARIETIES    OF    INTESTINAL 
OBSTRUCTION. 

From  the  clinical  point  of  view  cases  of  mtestinal  obstruction 
may  be  conveniently  divided  into  three  classes  : — (1)  Acute 
obstruction  ;  (2)  chronic  obstruction  ;  and  (3)  cases  in 
which  symptoms  of  acute  obstruction  supervene  on  those 
indicative  of  chronic  obstruction. 

The  symptoms  of  intestinal  obstruction  are  liable  to 
considerable  variation,  and  it  is  not  to  be  claimed  with 
certainty  that  a  particular  pathological  condition  causing 
obstruction  will  always  be  attended  with  particular  and 
unvarying  symptoms. 

The  general  features  of  the  three  types  of  intestinal 
obstruction  are  here  set  out  in  brief  outline.  The  more 
detailed  account  of  each  form  will  be  found  on  pages  823, 
391  and  435  respectively. 

1.  Acute  Intestinal  Obstruction. — The  attack  is  sudden 
in  onset.  In  the  majority  of  instances  no  exciting  cause  is 
apparent. 

The  patient  is  seized  with  very  seA^ere  abdominal  pain. 
This  is  generally  localised  about  the  umbilicus,  that  is,  about 
the  great  nerve  centre  for  the  intestine.  Sometimes  the 
pain  corresponds  to  the  seat  of  the  obstruction,  but  not 
commonly.  The  patient  may  be  "  doubled  up "  by  it  or 
roll  in  anguish  on  the  floor.  The  pain  is  of  the  nature  of 
colic,  and  is  usually  constant,  although  liable  to  exacer- 
bations. There  is  at  first,  at  least,  little  or  no  tenderness 
of  the  abdomen. 

There  is  colkqjse,  with  great  depression  of  strength,  pallor, 
sunken  eyes,  a  feeble  rapid  pulse,  a  cold  sweat  over  the 
face,  a  sighing  respiration.      Vo'initing  appears  early,  is  first 


28G  CHRONIC    OBSTRUCTION. 

composed  of  the  contents  of  the  stomach,  is  then  bihoiis,  and 
later  brownish  and  offensive.  It  is  copious  and  persistent, 
gives  httle  or  no  rehef,  and  in  time  very  usually  becomes 
stercoraceous.  There  is  const ijiat ion,  which  is  usually  abso- 
lute from  the  first.  The  belly  becomes  more  or  less  distended, 
and  towards  the  end  of  the  case  is  apt  to  become  tender. 
The  tongue  is  foully  coated.  Thirst  is  intense.  The  tetwpera- 
ture  is  below  normal.     The  amount  of  urine  is  diminished. 

If  unrelieved,  the  symptoms  persist,  the  exhaustion 
increases  rapidly,  the  tongue  becomes  dry  and  brown,  the 
face  has  an  aspect  of  horrible  anxiety,  the  features  are 
pinched,  and  the  eyes  sunken.  The  patient  dies  with  those 
symptoms  of  septic  poisoning  which  mark  the  termination 
of  acute  peritonitis.  There  may  be  delirium,  but  as  a  rule 
the  patient  retains  consciousness  to  the  last.  The  vonuting 
usually  remains  the  most  distressing  symptom. 

The  majority  of  the  acute  cases  die,  if  unrelieved,  within 
six  or  seven  days.  The  varieties  of  acute  obstruction  are 
enumerated  on  page  321. 

The  most  characteristic  forms  are  met  with  in  association 
Avith  strangulation  by  a  band,  volvulus  of  the  sigmoid  flexure, 
acute  intussusception  and  acute  and  abrupt  blocking  of  the 
bowel  by  a  gall  stone  or  foreign  body.  The  detailed  account 
of  the  symptoms  of  acute  obstruction  will  be  found  on 
page  823. 

2.  Chronic  Intestinal  Obstruction. — The  onset  in  this 
form  of  obstruction  is  gradual,  and  the  progress  of  the 
malady  irregular.  There  are  attacks  of  abdominal  pain 
which  are  not  severe,  which  come  on  at  first  at  long  intervals, 
are  often  provoked  by  food,  and  are  frequently  ascribed  to 
indigestion  or  colic.  These  attacks  become  in  time  more 
frequent,  more  severe,  and  of  longer  duration.  They  are 
attended  with  some  vomiting  and  constipation,  and  with 
more  or  less  constant  uneasiness  within  the  abdomen.  The 
vomiting  is  probably  slight,  and  does  not  persist.  There 
may,  however,  remain  much  nausea  and  disinclination  for 
food. 

The  constipation  is  not  at  first  absolute.  The  patient  is 
in  the  early  stages  relieved  by  aperients.  These  drugs  then 
act  with  less  and  less  effect,  and  at  last  only  occasion  severe 
pain  and  vomiting.  Sometimes  there  is  a  period  marked 
by  diarrhoea.  This  diarrhoea  is  "  spurious."  It  is  due  to 
catarrh  excited  in  the  bowel  by  retained  ftecal  matter  above 
the  obstruction,  and  is  only  met  with  when  the  stenosis  is 
somewhat  low  down  in  the  colon.  Between  these  attacks 
the  patient  may  feel  fairlj^  well,  and  suffer  only  from  some 


CLINWAL    VARIETIES    OF    OBSTRUGTIOX.  287 

abdominal  distension,  inegularity  of  the  boAvels,  nausea, 
malaise,  and  loss  of  appetite. 

The  tongue  becomes  white  and  coated,  and  the  breath 
often  most  offensive.  The  te'inperature  is  not  usually  dis- 
turbed, nor  is  the  amount  of  urine  passed  abnormal.  The 
belly  becomes  more  and  more  distended.  A  tumour  is  often 
discovered.  Evidence  of  an  accumulation  of  foices  is  often 
present.  Visible  coils  of  intestine  can  be  seen  in  movement 
through  the  apparently  thinned  abdominal  parietes.  When 
the  movement  takes  place  the  patient  has  pain.  There 
are  frequent  rumbling  and  gurgling  sounds  in  the  abrlomen, 
which  are  very  audible  to  those  around. 

The  pain  becomes  more  continuous  and  more  severe, 
the  vomiting  is  more  persistent,  the  constipation  is  at  last 
almost  absolute,  the  distension  of  the  belly  increases,  and  the 
strength  rapidly  fails. 

Unless  some  accident,  such  as  perforation,  occurs,  the 
patient  (if  unrelieved)  dies  exhausted  and  marasmic,  worn 
out  by  the  continued  pain  and  vomiting,  wasted  by  inability 
to  take  food,  and  poisoned  by  the  absorption  of  noxious 
matter  from  the  horribly  putrid  contents  of  his  own  intes- 
tine. The  breath  has  often  at  last  a  perfectly  fsecal  odour. 
Death  may  be  said  to  occur,  if  the  general  courses  of  chronic 
obstruction  be  considered,  in  some  six  months  after  the 
onset  of  the  symptoms  of  obstruction.  The  varieties  of 
chronic  obstruction  are  detailed  on  page  322. 

The  most  characteristic  forms  are  illustrated  by  stricture 
of  the  bowel,  by  gradual  compression  of  the  bowel  by  a 
tumour  growing  outside  its  walls,  by  the  gradual  tilling 
of  the  lumen  of  the  bowel  by  a  tumour  growing  from  its 
actual  coats. 

The  detailed  account  of  the  symptoms  of  chronic  obstruc- 
tion will  be  found  on  page  391. 

3.  Chronic  Intestinal  Obstruction  Ending  Acutely. — 
This  class  of  case  is  not  uncommon.  The  patient  has  some 
obstruction  in  the  bowel  which  does  not  completely  block 
it.  He  has  the  symptoms  of  chronic  obstruction.  Upon 
these  are  suddenly  engrafted  the  phenomena  of  acute,  or 
subacute  obstruction.  This  sudden  alteration  may  be  due 
to  many  causes.  There  may  be  a  very  narrow  stricture 
which  has  become  suddenly  blocked  by  a  mass  of  undigested 
food  or  by  some  foreign  body  that  has  been  swallowed.  These 
acute  attacks  are  very  often  induced  b}'  a  brisk  aperient : 
occasionally  they  come  on  after  violent  exertion. 

In  other  cases  the  stenosed  bowel  has  been  kinked  or 
acutely  bent  upon  itself  and  so  closed,  or  it  has  beconie  rhe 


288  CLINICAL    VARIETIES    OF    OBSTIIUGTION. 

seat  of  a  volvulus  or  of  an  intussusception.  Very  often  a 
slight  attack  of  peritonitis — due  probably  to  ulceration  above 
a  stricture — will  bring  on  the  phenomena  of  acute  obstruc- 
tion. In  not  a  few  instances  attention  has  been  first  called 
to  a  malignant  stricture  of  the  colon  by  an  attack  of  sub- 
acute obstruction,  the  patient  having  previously  complained 
only  of  dj^spepsia,  constipation,  and  colic.  A  case  of  fascal 
accumulation  may  end  with  acute  symptoms  due  to  con- 
ditions which  have  been  alluded  to  in  dealing  with  the 
so-called  "  ileus  paralyticus "  (page  280).  This  variety  of 
obstruction  is  further  dealt  with  on  pages  322  and  435. 


289; 


CHAPTER    II. 
THE  SIGNIFICANCE  OF  THE  LEADING  SYMPTOMS. 

1.  Collapse. — Collapse  as  an  early  symptom  is  seen  only; 
in  cases  of  acute  obstruction.  It  is  due,  not  to  the  abrupt 
arrest  of  the  movement  of  the  intestinal  contents,  but  to 
the  sudden  and  severe  lesion  inflicted  upon  the  intestinal 
and  peritoneal  nerves.  It  has,  indeed,  nothing  to  do  with 
the  mere  obstructing  of  the  alimentary  canal. 

In  a  certain  exact  sense,  collapse  is  not  a  symptom  of 
intestinal  obstruption.  The  collapse  met  with  is  precisely 
similar  to  that  which  attends  nearly  all  acute  lesions  within 
the  abdomen,  all  lesions  at  least  which  present  the  common 
factor  of  a  sudden  and  severe  impression  made  upon  the 
peritoneal  and  visceral  nerves.  The  signs  of  a  sudden  and 
painful  disturbance  within  the  peritoneal  cavity  are  those 
of  collapse,  together  with  pain  and  vomiting. 

There  are  pain,  profound  exhaustion,  a  distressful  anxiety, 
pallor,  a  small  soft,  quick  pulse,  cold  extremities,  sweating, 
shallow  respiration  and  vomiting.  These  phenomena  vary  in 
prominence  and  intensity,  but  they  are  in  some  degree 
common  to  all  cases  in  which  there  has  been  a  rude  and 
abrupt  impression  made  upon  the  nerve  centres  within  the 
abdomen.  It  may  almost  be  said  that  all  quite  acute 
troubles  within  the  abdomen  commence  with  the  same  train 
of  symptoms.  A  student  who  is  well  versed  in  the  rigidly 
formulated  signs  of  abdominal  lesions  as  given  in  text- 
books is  surprised  to  be  told  that  until  many  hours  have 
elapsed  it  is  often  impossible  to  say  whether  a  sudden 
abdominal  crisis  is  due  to  the  perforation  of  a  vermiform 
appendix,  or  to  the  bursting  of  a  pyo-salpinx,  or  to  the 
passage  of  a  gall  stone,  or  to  the  strangulation  of  a  loop 
of  intestine.  The  twisting  of  the  pedicle  of  an  ovarian 
cyst  has  led  to  symptoms  which  have  been  mistaken  for 
T 


290  CLINICAL    MANIFESTATION'S. 

perityphlitis;  a  sudden  peritoneal  haemorrhage  has  been 
confused  with  intestinal  obstruction;  and  the  rupture  of  a 
hydatid  cyst  has  been  diagnosed  as  a  perforation  of  the 
intestine.  It  is  quite  possible — indeed,  quite  usual — for 
these  various  troubles  to  present  at  first  symptoms  which 
are  common  to  them  all,  and  which  merely  indicate  that 
an  abrupt  and  painful  impression  has  been  made  upon  the 
abdominal  nervous  system.  Often  at  first  there  are  no 
differentiating  symptoms.  There  may  be  features  in  the 
past  history  of  the  patient  which  indicate  a  diagnosis,  but 
in  the  absence  of  such  evidence  the  cautious  surgeon  is 
simply  assured  that  some  sudden  emergency  has  occurred 
within  the  peritoneal  area,  and  that  he  must  wait  for  localis- 
ing signs  before  he  can  offer  a  diagnosis.  To  these  common 
phenomena  of  a  crisis  within  the  abdomen  Gtibler^  has 
applied  the  convenient  term  of  "peritonism." 

Into  the  physiological  processes  involved  in  the  pro- 
duction of  the  symptoms  of  collapse  it  is  not  necessary 
here  to  enter.  The  matter  has  been  fully  investigated  by 
means  of  vivisection  experiments,  and  has  been  illustrated 
by  the  effects  of  injury  and  disease  occurring  in  the  human 
subject.  It  has  been  shown  that  the  manifestations  of 
collapse  depend  upon  a  profound  impression  upon  the 
nervous  system,  an  impression  that  acts  inainly  through 
the  sympathetic  centres  and  displays  itself  through  certain 
grave  and  violent  vascular  disturbances.  There  is  marked 
inequality  in  the  distribution  of  the  blood.  The  altered 
circulatory  conditions  are  made  evident  by  the  lowering  of 
the  temperature  of  the  surface,  by  the  cold  sweats,  by 
the  frequent  lividity  of  the  extremities,  by  the  aneemia 
of  the  brain,  by  the  small,  rapid  and  empty  pulse. 

The  disturbance  is  a  reflex  one,  which  varies  in  degree 
and  extent  according  to  the  severity  of  the  lesion. 

It  is  said  by  some  that  the  pulse  is  rendered  slower  at  the 
very  onset  of  the  strangulation  of  the  bowel,  and  that  an 
appreciable  time  elapses  before  it  assumes  the  familiar 
rapidity  of  beat.  Clinical  evidence  as  to  this  point  is, 
however,  difficult  to  obtain.  There  is  hypersemia  of  the 
abdominal  organs  which  tends  to  increase  the  difficulties  of 
the  snared  bowel.  Not  only  is  the  temperature  of  the  skin 
reduced,  but  also  the  temperature  within  the  rectum.  It  is 
therefore  assumed  by  some  that  there  is,  in  collapse,  a 
reflex  disturbance  of  the  heat-regulating  centres. 

The  severity  of  the  initial  shock,  which  is  so  marked  a 
feature  at  the  onset  of  acute  intestinal  obstruction,  depends 

*  Journ.  de  Therap.,  1877. 


COLLAPSE.  291 

Upon  the  suddenness  of  the  strangulation,  its  rigour,  the 
amount  and  nature  of  the  gut  involved.  It  is  more  marked 
when  the  small  bowel  is  concerned  as  compared  with  the. 
colon,  and  in  the  lesser  bowel  it  is  the  more  severe  as  the 
stomach  is  approached.  If  regard  be  had  for  the  nerve 
supply  and  nerve  associations  of  the  different  parts  of  the 
alimentary  canal,  this  is  precisely  what  Avould  be  expected. 
It  is  surprising  how  profound  a  degree  of  collapse  may 
attend  the  snaring  of  quite  a  small  loop  of  jejunum, 
providing  that  such  snaring  be  abrupt  and  intense.  The 
amount  of  bowel  implicated  must,  of  course,  play  an  im- 
portant part,  and  I  have  seen  intense  collapse  attend  an 
acute  volvulus  implicating  the  whole  of  the  sigmoid  flexure. 
Clinical  experience  shows,  by-the-bye,  that  the  sigmoid 
flexure  possesses — when  compared  with  the  rest  of  the. 
colon — a  very  susceptible  and  responsive  nervous  apparatus. 
In  certain  disordered  conditions  it  exhibits  quite  a  high 
degree  of  nerve  irritability,  Avhich  throws  it  into  marked 
contrast  with  the  rest  of  the  somewhat  dull  and  apathetic 
colon. 

I  have  met  with  several  instances  in  Avhich  quite 
moderate  collapse  has  attended  the  strangulation  of  a 
voluminous  coil  of  small  intestine.  When  the  abdomen 
has  been  opened  in  these  cases,  it  has  been  a  matter  of 
surprise  that  the  patient  has  not  exhibited  a  more  profound 
degree  of  shock.  This  circumstance  is,  however,  explained  by 
the  fact  that  it  is  ditficult  to  bring  about  intense  and  abrupt, 
strangulation  in  a  voluminous  coil,  and  that  a  coil  so  snared 
is  likely  to  undergo  somewhat  slowly  the  after-changes  which 
attend  upon  strangulation.  The  most  profound  degrees  of 
collapse  which  I  have  noticed  have  been  associated  with 
cases  in  which  a  few  inches  of  the  jejunum  have  been 
abruptly  and  violently  strangulated  by  a  small  cord-like 
band ;  the  patient  being  at  the  time  of  the  accident  in 
perfect  health. 

The  collapse  at  the  outset  of  acute  intestinal  obstruction 
will  obviously  be  influenced  by  the  age  and  general  condition 
of  the  patient.  It  is  most  marked  in  the  young  adult  who 
is  full  of  life  and  vigour  at  the  time  of  the  lesion.  In  quite 
old  patients  it  is  remarkable  how  comparatively  slight  the 
degree  of  collapse  may  often  be  and  how  attenuated  are  its 
manifestations. 

There  are,  however,  certain  conditions  and  states  of  the 
individual  which  appear  to  modify  the  effect  of  shock  in 
a  manner  which  cannot  be  explained. 

I  have  encountered  a  case  in  which  an  alarmingf  degfree 


292  GLIXIGAL   MANIFESTATIONS. 

of  shock  has  attended  a  strangulation  of  the  bowel  which 
proved  on  operation  to  be  of  quite  moderate  degree,  while- 
on  the  other  hand  I  recall  the  case  of  a  lady  of  thirty 
whose  abdomen  I  opened  on  the  seventh  day  after  the  , 
onset  of  obstruction  symptoms,  to  find  a  coil  of  ileum 
almost  cut  in  two  by  a  cord-like  band,  and  yet  whose  ; 
early  symptoms  had  at  no  time  amounted  to  what  could  be 
called  collapse. 

In  soine  instances  the  collapse  may  be  so  profound  as. , 
to  resemble  the  collapse  of  cholera.  The  resemblance  is 
especially  marked  when  the  case  is  associated  with  muscular  , 
cramps  (usually  of  the  lower  limbs)  and  possibly  with  some 
degree  of  diarrhoea.  Not  a  few  cases  have  been  recorded  in 
which  acute  intestinal  obstruction  has  been  without  hesita- 
tion diagnosed  as  cholera. 

,  So  far  allusion  has  been  made  only  to  the  initial  collapse 
in  acute  obstruction  of  the  bowels,  and  it  remains  to  be 
mentioned  that  a  condition  of  collapse  of  a  somewhat  dif- 
ferent type  very  usually  precedes  death  in  those  cases  which 
end  fatally.  This  terminal  collapse  may  mark  the  close  of_, 
any  case  of  intestinal  obstruction  whether  it  has  been  acute 
or  chronic  in  its  course. 

In  an  acute  case,  for  example,  the  collapse  which  ushers 
in  the  clinical  manifestations  passes  away ;  the  pain  is  more 
or  less  entirely  relieved  by  morphia ;  the  vomiting  and  other 
phenomena  of  obstruction  remain,  yet  the  patient's  pulse  has. 
recovered  itself     Various  medical  measures  of  treatment  are 
employed,    and    a     certain    delusive    improvement    in    the-: 
patient's  state  may   be  claimed.     About   the   fifth   or  sixth 
day,  however,  he  passes  into  an  insidious  condition  of  collapse,,, 
and  on  the  seventh  day  he  dies.     This  collapse  is  identical , 
with  that  which  marks  the  end  of  a  case  of  fatal  peritonitis,,, 
and  there  is  no  doubt  but  that  it  is  due  to  auto-intoxication, 
to  self- poisoning,  and  that  it  merits  the  term  employed  by 
some  of  "  septic  collapse." 

There  is  about  the   patient  who  is  dying   of  peritonitis, 
or   of  acute    intestinal    obstruction   every    suggestion   of    a 
poisoned  man.     He  lies  back  in  bed  prostrate,  with  gaunt, 
cheeks  and  sunken  eyes.     His  pain  has  vanished,  but  some 
haunting  fear  has  taken  its  place.     The  hands,  which  wander , 
with  pathetic  restlessness  over  the  bed-clothes,  are  cold  and^ 
damp.     Beads  of  sweat  stand  upon  the  brow.     The  tongue  is. 
that  of  a  man  who  is  dying  of  thirst.     There  is  still  continued 
vomiting.      The  pulse  has  sunk  to    an  uncountable  thread. 
The  breathing  is  laboured  and  accompanied  with  faint  sighs , 
and  groans,  and  the,  countenance  is  ashen  and  livid.     Such  a^ 


PAm.  293 

picture  makes  a  reality  of  the  metaphor  of  "  the  shadow  of 
death." 

So  far  as  the  aspect  of  the  patient  goes,  he  may  be  dying 
from  snake-bite  or  from  the  poison  of  cholera.  He  is,  in 
actual  fact,  dying  of  poison  derived  from  his  own  intestine. 
The  contents  of  the  bowel  are  loaded  with  the  products  of 
putrefaction  and  with  the  toxins  of  innumerable  bacteria. 
The  bowel  wall  is  damaged  and  can  no  longer  prevent  the 
■escape  of  these  potent  poisons,  and  their  escape  is  followed  by 
that  collapse  which  ends  in  death. 

2.  Pain. — This  symptom,  which  is  so  conspicuous  a 
feature  in  intestinal  obstruction,  depends  upon  several 
-conditions.  It  is  due,  in  the  first  instance,  to  the 
lesion  experienced  by  the  peritoneum  and  by  the  intestinal 
walls  as  a  result  of  the  strangulation.  Its  severity  will 
be  measured  by  the  suddenness  of  the  strangulation,  the 
amount  of  bowel  involved,  and  upon  other  obvious  circum- 
stances. It  depends  at  a  somewhat  later  period,  or  in  the 
first  instance  in  certain  cases,  upon  the  tumultuous,  irregular, 
and  futile  peristaltic  movements  excited  in  the  intestine. 
These  movements  are  more  or  less  arrested  at  the  seat  of 
■obstruction,  and  the  peristaltic  wave,  no  longer  moving 
regularly,  leads  to  disordered  muscular  contractions  that  are 
the  basis  of  the  symptoms  known  as  "  colic."  There  is  no 
doubt  but  that  by  the  undue  reflex  action  excited  by  the  peri- 
toneal lesion,  and  by  the  actual  obstruction,  the  movements 
in  the  bowel  above  the  occlusion  become  for  a  time  unusually 
vigorous.  The  periodical  exacerbations  of  pain  are  due  to  the 
passage  along  the  intestine  of  periodic  peristaltic  waves  that 
hurl  themselves,  as  it  were,  against  the  obstruction.  This 
circumstance  can  often  be  well  displayed  in  chronic  cases 
associated  with  emaciation  and  with  visible  movement  of 
the  intestinal  coils.  As  time  advances,  the  nature  of  the  pain 
is  influenced  by  the  distension  of  the  gut  and  by  the  appear- 
ance or  non-appearance  of  peritonitis. 

In  general  terms,  it  may  be  said  that  the  pain  in  intestinal 
obstruction  is,  for  the  most  part,  a  colicky  pain.  The  patient 
feels  that  it  concerns  the  bowel.  It  appears  often  "  to  twist 
him  up."  There  is  a  sense  of  distension  or  of  something 
dragging  at  the  bowels ;  there  is  an  abiding  impression  that 
if  only  flatus  could  be  passed  the  pain  would  be  relieved. 
Many  say  that  when  the  pain  is  severe — for  example,  during 
a  paroxysm — they  feel  something  moving  in  the  abdomen, 
and  that  the  movement  is  always  arrested  at  the  same 
spot. 

There  is  no  doubt  but  that  the  pain  at  the  onset  of  an 


-294  CLIXICAL   MANIFESTATIOXS. 

■  9,ciite  obstruction  of  the  bowels  is  terrible  in  its  intensity,  and 
may  be  fitly  described  as  agonising. 

In  the  matter  of  diagnosis,  especial  attention  must  be 
called  to  a  feature  in  the  character  of  the  pain.  It  is  this :  In 
cases  where  the  obstruction  is  complete,  the  pain  is  constant, 
although  liable  to  periodic  exacerbations.  In  cases  where  the 
obstruction  is  but  partial  the  pain  is  distinctly  intermittent, 
and  the  individual  experiences  intervals  between  attacks  of 
pain,  during  which  he  is  free  from  suffering. 

To  this  rule  I  have  been  able  to  find  extremely  few  excep- 
tions that  may  be  regarded  as  satisfactory.  As  illustrations  of 
the  relationship,  I  might  draw  attention  to  the  constant  pain 
in  acute  strangulation  as  compared  with  the  markedly  inter- 
mittent pain  in  stricture.  If,  in  a  case  of  stricture,  the 
stenosed  segment  become  suddenh'  occluded,  the  nature  of  the 
pain  will  change  almost  as  suddenly,  and  will  become  con- 
.tinuous  where  before  it  was  purely  intermittent, 
r  Moreover,  one  observes  in  cases  of  stricture  that  as  the 
malady  advances,  and  as  the  narrowed  part  becomes  still 
more  narrow,  so  does  the  pain  appear  at  less  lengthy  intervals, 
until  at  last,  when  the  intestine  has  become  entirely  occluded, 
the  pain  will  have  become  also  more  or  less  continuous. 

The  pain  in  the  earlier  stages  of  intestinal  obstruction  is 
usually  not  aggravated  by  pressure.  It  is  imassociated,  in 
fact,  with  tenderness,  and  is,  indeed,  very  often  much  reheved 
b}"  compression  of  the  abdomen.  The  appearance  of  tender- 
-ness  is  coincident  with  great  hyperaemia  of  the  peritoneum,  or 
with  actual  peritonitis. 

The  diminution  in  the  severit}'  of  the  pain  which  is  not 
infrequently  experienced  towards  the  termination  of  a  fatal 
case  may  depend  upon  the  collapse  following  perforation,  or 
upon  diminished  activity  of  the  sensorium,  or  upon  extensive 
paralysis  of  the  intestine  as  a  result  of  peritonitis,  or  upon  a 
rupture  or  perforation  of  the  bowel  into  some  part  other  than 
the  peritoneal  cavity. 

The  great  increase  in  the  pain  which  is  often  experienced 
after  food,  or  after  the  use  of  enemata,  or  even  after  digital 
examination  of  the  rectum,  depends  upon  increased  retiex 
action  and  the  fresh  peristaltic  movement  that  it  excites. 

With  regard  to  the  situation  of  the  pain,  as  distinguished 
from  tenderness,  I  would  dissent  from  the  statement  that  it 
corresponds  to  the  seat  of  the  obstruction.  In  the  case  of  the 
small  intestines,  I  am  convinced,  not  only  that  the  situation  of 
the  pain  is  of  no  value  in  diagnosing  the  site  of  the  occlusion, 
but  that  it  is,  if  used  for  such  diagnostic  purposes,  usuallj^ 
misleading.     In  the  development  of  human  intelligence  the 


PAIN.  29;^ 

factors  upon  which  an  appreciation  of  position  and  distance 
are  founded  are  tolerably  well  known.  These  factors  are 
constant.  The  child  gradually  acquires,  by  slow  experience,  a 
knowledge  of  the  localisation  of  sensation  upon  various  parts 
of  its  integument.  There  is,  no  doubt,  a  period  in  its  existence 
when  painful  sensations  are  appreciated  solely  by  their  degree 
or  quality  without  any  reference  to  locality.  It  is  a  matter  of 
gradual  experience  to  distinguish  a  pain  on  the  back  of  the 
hand  from  one  on  the  back  of  the  shoulder.  The  factors  upon 
which  that  experience  is  founded  are  constant.  The  distances 
between  the  two  painful  spots  are  constant,  and  can  be  appre- 
ciated by  sight  as  well  as  by  feeling.  It  is  by  an  unconscious 
process  of  repeated  comparison  that  a  child  acquires  a  know- 
ledge of  its  own  skin,  or  of  its  own  skin  so  far  as  it  is  concerned 
as  a  vehicle  for  sensation.  With  regard  to  the  localisation  of 
sensation  in  the  intestine  (and  we  will  consider  particularly 
the  small  intestine),  it  must  be  remembered  that  the  length 
of  the  bowel  is  very  considerable  ;  that  the  coils  are  per- 
petually changing  their  position  and  altering  the  mutual 
relation  they  bear  to  one  another ;  and  that  the  part  is  not 
very  directly  supplied  with  spinal  nerves.  '  -"    \ 

In  fact,  the  small  intestine  at  least  does  not  possess  that 
arrangement  of  parts  which  we  are  apt  to  regard  as  essential 
for  the  proper  localisation  of  sensations  painful  or  otherwise! 
The  passage  of  a  large  foreign  body  along  the  lesser  bowel 
is  often  associated  with  great  and  long-continued  pain,  i  But 
neither  the  nature  nor  the  position  of  the  pain  appears  in 
any  way  to  assist  in  the  localisation  of  the  intruding  substance. 
If  the  passage  along  the  intestine  of  a  foreign  body,  capable  of 
exciting  pain  throughout  its  whole  progress,  were  a  matter 
of  daily  occurrence,  then  in  time  it  might  be  possible  for  an 
individual  to  localise  painful  sensations  in  certain  segments  of 
the  gut ;  but  even  such  an  experience  would  scarcely  allow 
of  pain  being  localised  in  one  very  limited  portion  of  a  tube 
which  is  many  feet  in  length. 

It  is  possible  that  a  human  being  with  a  transparent 
abdominal  wall  Avould  in  time  be  able— by  a  careful  watch- 
ing of  the  small  intestine — to  localise  pain  in  definite  sections 
of  that  bowel. 

In  the  case  of  the  stomach  and  of  the  colon  it  is  possible 
to  conceive  that  painful  sensations  occurring  in  those  parts 
may  be  more  or  less  definitely  localised,  since  they  are  more 
constant  in  position  and  in  the  relation  that  their  parts  bear 
to  one  another.  The  position  of  the  pain  in  gastric  ulcer, 
and  in  some  cases  of  cancer  of  the  large  intestine,  supports 
this  notion. 


296  CLINICAL    MANIFESTATIONS. 

(  In  both  these  instances,  however,  the  locaUsation  of  the 
pain  is  often  assisted  by  an  abiding  tenderness.  In  cases  of 
stricture  of  the  colon  associated  with  tenderness  the  seat 
of  the  trouble  is  very  often  found  to  correspond  to  the 
spot  indicated  by  the  patient.  When,  however,  there  is  no 
tender  spot  to  be  discovered,  abdominal  pain  is  of  very  little 
use  in  defining  the  site  of  a  stenosed  part  of  the  large  intes- 
tine. Over  and  over  again  have  surgeons  been  deceived 
on  this  point.  In  instances  of  stricture  of  the  colon  asso- 
ciated with  visible  and  painful  peristaltic  movements,  the 
spot  where  the  movements  appear  to  lead  to,  and  at  which 
they  are  arrested,  is  often  the  spot  at  which  the  stricture 
is  located.  The  patient  will  sometimes  declare  that  he 
can  appreciate  that  the  movement  in  the  intestinal  coil  is 
always  arrested  at  the  same  locality.  Even  with  these 
additional  aids  to  localisation  it  is  often  found  that  the 
site  indicated  by  the  patient,  and  considered  probable  by 
the  surgeon,  does  not  correspond  to  the  actual  seat  of  the 
disease. 

I  can  remember  a  case  of  stenosis  of  the  colon  in  which 
there  were  pain  and  tenderness  in  the  depths  of  the  right 
iliac  fossa.  Visible  peristaltic  movements  were  present  and 
appeared  to  lead  to  this  region.  The  patient  was  convinced 
that  the  "stoppage"  was  situated  in  the  csecal  region, 
but  subsequent  surgical  procedures  displayed  an  epithelioma 
of  the  upper  part  of  the  rectum. 

In  cases  of  acute  intestinal  obstruction  the  initial  pain 
is  commonly  referred  to  the  region  of  the  umbilicus,  or  to 
a  point  in  the  median  line  a  little  above  that  cicatrix.  The 
initial  pain  in  a  strangulated  hernia — especially  when  the 
sac  contains  small  intestine — is  very  usually  referred  to  the 
umbilical  region. 

The  region  thus  indicated  corresponds  to  the  site  of 
the  superior  mesenteric  and  solar  plexuses,  and  there  is  no 
doubt  but  that  it  is  to  these  great  nerve  centres  of  the 
abdomen  that  the  pain  is  referred. 

The  initial  pain  in  the  first  attack  of  acute  perityphlitis 
is  nearly  always  referred  to  the  umbilical  region. 

A  patient  may  place  his  hand  over  the  umbilicus  to 
indicate  the  exact  seat  of  his  pain,  and  yet  the  cause  of  the 
trouble  may  be  the  strangulation  of  a  loop  of  ileum  deep 
down  in  the  pelvis  or  in  one  or  other  of  the  iliac  fossae. 
The  early  intense  pain  of  acute  strangulation  is,  no  doubt, 
very  diffused,  and  the  hand  placed  over  the  umbilicus  does, 
perhaps,  little  more  than  indicate  that  the  distress  is 
situated  in  the  abdomen.  ' 


VOMITING.  297 

As  time  goes  on,  the  seat  of  the  strangulation  may  be 
indicated  as  the  site  of  the  pain.  This  is  quite  probable 
if  one  recalls  the  gross  changes  which  are  taking  place  in 
and  about  the  snared  bowel,  the  local  peritonitis  which 
is  being  induced  and  the  tenderness  which  can  scarcely 
be  absent. 

I  have  noticed  that  in  trouble  in  the  descending  colon 
and  sigmoid  flexure  pain  is  very  often  referred  to  a  spot  just 
to  the  left  of  the  umbilicus.  This  is  especially  to  be  noticed 
when  the  sigmoid  flexure  is  concerned,  and  is  well  marked 
in  cases  in  which  that  bowel  has  long  been  the  seat  of 
catarrhal  inflammation. 

The  spot  so  emphatically  indicated  in  many  of  these 
instances  appears  to  correspond  roughly  to  the  inferior 
mesenteric  plexus. 

It  must  also  be  borne  in  mind  that  a  painful  trouble  in 
one  side  of  the  abdomen  may  lead  to  pain  in  the  opposite 
side  of  that  cavity. 

For  example,  instances  have  be^n  noted  in  which  stone 
in  one  kidney  has  been  associated  with  pain  in  the  opposite 
and  sound  organ.  I  have  seen  cases  of  disease  of  a  normally 
placed  vermiform  appendix  in  which  all  the  pain  was  referred 
to  the  left  iliac  fossa.  In  one  of  these  instances  pressure 
upon  the  diseased  appendix  induced  pain,  not  over  the  point 
of  pressure,  but  m  the  opposite  iliac  fossa.  I  have  removed 
an  appendix  full  of  pus  from  a  patient  whose  symptoms 
were  always  referred  to  the  left  side  of  the  abdomen. 

I  have  alluded  elsewhere  to  a  case  in  which,  after 
cholecystotomy,  I  was  cutting  away  some  redundant  gall 
bladder  which  had  been  brought  out  of  the  wound.  The 
patient  was  not  anaesthetised,  and  the  operation  was  only 
complained  of  as  causing  pain  at  a  spot  under  the  left 
lower  ribs. 

In  intestinal  obstruction  instances  now  and  then  present 
themselves  in  which  the  chief  pain  complained  of  is  on  the 
opposite  side  of  the  abdomen  to  the  seat  of  the  bowel  lesion. 

3.  Vomiting. — Yomiting  is  one  of  the  most  common 
and  most  marked  of  the  symptoms  of  intestinal  obstruction. 
It  may  be  considered  under  three  headings: — 

(1)  The  vomiting  which  appears  at  the  very  commence- 
ment  of  an  acute  case  is  no  doubt  reflex,  and  is  of  precisely 
the  same  nature  as  the  vomiting  which  may  follow  a  wound 
of  the  abdomen  or  a  crush  of  the  testicle.  Such  sickness 
may  be  coincident  with  the  initial  pain  and  be  one  of  the 
very  earliest  manifestations.  The  patient  is  seized  with 
violent  pain  in  the  abdomen  and  at  once  vomits.     Marked 


298  OLINIGAL  MANIFESTATIONS. 

vomiting  at  the  very  onset  of  the  attack  is  nciost  commonly 
met  with  in  children  and  young  adults.  It  is  obviously 
modified  by  the  circumstances  which  influence  reflex 
vomiting,  such  as  the  state  and  nerve  pebuliarities  of  the 
patient,' the  sensibility  of  the  part  of  bowel  damaged,  and 
the  condition  of  the  stomach.  Some  individuals  vomit  on 
the  least  provocation ;  others  assert  that  nothing  ever  makes 
them  sick,  and  that  with  them  vomiting  is  unknown.  I 
recall  the  case  of  a  sensitive  girl  of  twelve  whose  vermiform 
appendix  I  had  removed  for  relapsing  perityphlitis.  Her 
attacks  had  been  associated  with  considerable  vomiting,  and, 
as  her  mother  expressed  it,  "  the  least  thing  made  her  sick." 
The  slight  pain  caused  by  the  removal  of  the  wound  sutures 
on  the  tenth  day  produced  a  sudden  and  copious  vomiting, 
which  was  evidently  reflex. 

It  is  needless  to  say  that  this  initial  vomiting  is  influenced 
by  the  amount  of  food  contained  in  the  stomach.  If  strangu- 
lation of  the  bowel  occur  immediately  after  a  full  meal,  it  is 
a  matter  of  almost  absolute  certainty  that  vomiting  will  be 
prompt,  and  that  the  whole  viscus  will  be  emptied.  If,  how- 
ever, the  organ  be  quite  empty  at  the  time  of  the  accident, 
vomiting  may  not  be  among  the  early  manifestations. 

(2)  The  vomiting  which  marks  the  dose  of  a  fatal  case 
of  intestinal  obstruction  may  be  due  to  the  obstruction 
itself,  but  it  is  very  often  the  vomiting  of  a  rapidly-increasing 
septicaemia.  Such  vomiting  may  continue  after  the  strangu- 
lation has  been  relieved,  and  even  after  an  artificial  opening 
in  the  bowel  has  been  made.  In  such  a  case  the  continued 
sickness  is  the  sickness  of  peritonitis  and  the  septicsemic  con- 
dition-which  is  so  prominently  associated  with  that  affection. 

(3)  The  vomiting  which  occurs  during  the  ])'^''og'fess  of 
intestinal  obstruction,  excluding  the  initial  vomiting  in  acute 
cases  and  the  final  vomiting  in  fatal  cases,  depends  for  the 
most  part  upon  the  actual  obstruction  in  the  lumen  of 
'the  bowel.    ' 

The  Character  of  the  Vomit. — The  vomiting  in  intes- 
tinal obstruction  is  characterised  by  its  early  onset,  its 
persistence;  and  its  copiousness.  At  first  the  contents  of 
the  stomach  are  evacuated.  Then  the  ejected  matter  is 
bilious,  and  may  be  composed  apparently  of  pure  bile.  In 
the  next  stage^f  the  case  progress — the  matter  is  usually 
thin  and  of  a  brownish  colour,  or  it  may  be  comparable 
to  pea  soup  or  be  of  a  yellow  tint  like  the  yolk  of 
eg^.  The  vomited  matters  soon  attain  what  is  called 
an  ''intestinal  odour."  Finally,  the  matter  vomited  becomes 
stercoraceous,  which  means  that  it  has  the  odour  of  fsecal 


VOMITING.  299 

matter.  The  term  stercoraceoiis  does  not  imply  that  the 
vomited  matter  is  composed  of  faces.  Fiecal  vomiting  is 
a  symptom  of  very  doubtful  existence,  and  is  only  met  with 
in  quite  peculiar  and  rare  circumstances.  I  have  never 
met  with  an  example  of  fcecal  vomiting  in  any  case  of  intes- 
tinal obstruction  that  I  have  seen.  I  assume  that  the  term 
"fseces"  is  limited  to  the  contents  of  the  lower  part  of  the 
colon,  or  possibly  to  the  contents  of  any  part  of  the  colon. 
The  contents  of  the  lower  ileum  have  often  the  distinct 
characters  of  soft  fa3cal  matter  in  normal  circumstances. 

It  was  at  one  time  assumed  that  in  any  case  of  sterco- 
raceous  vomiting  the  obstruction  was  low  down  in  the  colon, 
and  that,  as  the  result  of  the  block  in  the  bowel,  the  fsecai 
contents  of  the  gut  were  returned  through  the  ileo-csecal 
valve  into  the  small  intestine,  and  thence  into  the  stomach. 
This  assumption  has  long  since  been  proved  to  be  without 
foundation. 

Stercoraceous  vomit,  i.e.  vomit  which  has  a  fascal  odour, 
is  usually  met  with  in  obstruction  of  the  small  intestine, 
and  is  quite  uncommon  in  obstruction  of  the  colon.  Sterco- 
raceous vomiting  may  occur  when  the  obstruction  is  high 
up  in  the  jejunum.  Indeed,  Dr.  Pye  Smith  "^  describes  a 
case  of  cancerous  stricture  in  the  upper  part  of  the 
duodenum,  in  which  the  vomited  matter  had  "  a  strong 
and  decidedly  fsecal  odour."  The  very  existence  of  such 
vomiting  is  used  as  evidence  that  any  given  obstruction  is 
not  in  the  colon. 

Stercoraceous  vomiting  is  tested  by  its  odour,  and,  having 
regard  to  the  origin  of  the  term  stercoraceous,  the  adjective  is 
suited  to  the  condition  it  professes  to  define. 

The  patient  vomits  matter  that  has  about  it  the  sugges- 
tion of  fteces.  The  odoui"  is,  however,  not  always  that  of 
fseces,  and  certainly  not  that  of  healthy  fseces.  It  is  intensely 
offensive,  and  this  offensiveness  suggests  the  term  sterco- 
raceous. The  colour  of  this  filthy  fluid  varies.  It  may  be 
a  dirty  brown  or  a  dirty  yellow,  or  a  yellowish  green  or  a 
greyish  brown.  It  is  always  watery.  It  is  like  the  matter 
voided  in  diarrhoea.  It  never  contains  scybala  or  actual 
fsecal  masses  or  fsecal  matter.  Lumps  with  some  resemblance 
to  scybala  are  occasionally  seen  in  the  vomit.  They  are 
probably  masses  of  coagulated  milk  stained  with  bile,  and 
covered  with  the  foul  fluid  from  the  bowel. 

When  the  obstruction  is  in  the  small  intestine,  the 
fseculent  character  is  given  to  the  contents  of  the  bowel  by 
certain  decompositions  due  to  the  bacteria  present.      Those 

■  - '■•  Path.  Soc.  Trans.,  1894,  p.  63. 


(300  CLINIC AI^    MANIFESTATIONS. 

decompositions  lead  not  only  to  intensely  foul-smelling  pro- 
ducts, but  also  to  intensely  poisonous  substances.  Nothing  in 
the  human  body  can  be  more  foul  than  the  contents  of  the  gut 
in  a  case  of  obstruction  of  the  small  intestine.  The  bowel 
wall  is  damaged,  its  circulatory  condition  is  disturbed,  its 
normal  course  of  peristaltic  movement  is  arrested,  its  contents 
cannot  escape,  the  phenomena  of  normal  digestion  are 
wanting,  and  bacterial  growth  is  rampant.  The  result  is  that 
the  fluid  contained  in  the  involved  bowel  becomes  foul 
beyond  description,  and  if  it  be  poured  into  the  stomach 
and  vomited  it  merits  the  term  stercoraceous. 

The  colon  seems  better  able  to  deal  with  decomposing  con- 
tents, or  such  contents  are  retained  by  that  bowel  with 
less  manifold  inconvenience.  This  is  what  may  be  expected. 
The  lesser  bowel  is  accustomed  to  contain  food  in  process  of 
digestion,  the  colon — or  rather  the  lower  part  of  it — is  accus- 
tomed to  contain  fseces  and  food  refuse  in  process  of  decom- 
position. Stercoraceous  vomiting  is  more  common  and  appears 
earlier  in  obstruction  of  the  lesser  bowel  than  of  the  colon. 

When  the  obstruction  occupies  the  duodenum  or  upper 
jejunum,  the  vomited  matters  are  usually  very  copious  and 
always  deeply  stained  by  bile.  They  can  never  become  really 
stercoraceous,  although,  if  long  retained,  they  become  dis- 
coloured and  acquire  by  decomposition  an  odour  which  is 
very  offensive  and  which  is  often  described  as  "  intestinal." 

Allusion  has  just  been  made  to  a  case  of  Dr.  Pye  Smith's, 
in  which  vomitinsr  of  matter  with  a  fsecal  odour  occurred  with 
stricture  of  the  duodenum. 

The  Production  of  Stercoraceous  Vomiting. — The  |Dro- 
duction  of  stercoraceous  vomiting  has  been  the  subject 
of  much  discussion,  not  a  little  of  which  is  utterly  super- 
fluous. When  it  was  assumed  that  stercoraceous  vomiting 
was  the  vomiting  of  actual  fsecal  matter,  it  was  assumed  also 
that  it  depended  upon  an  obstruction  in  the  colon,  and  that 
faeces  regurgitated  through  the  ileo-csecal  valve  into  the  small 
intestine  and  thence  into  the  stomach.  It  has,  however,  now 
been  shown  that  stercoraceous  vomit  is  not  composed  of  faeces, 
and,  moreover,  that  this  symptom  is  very  much  more  common 
in  obstruction  of  the  lesser  bowel  than  in  occlusion  of  the 
colon.  Indeed,  stercoraceous  vomiting  is  a  feature  in  small- 
gut  obstruction.  It  is,  therefore,  no  longer  necessary  to  assume 
that  when  this  symptom  exists  there  is  any  insufficiency  of  the 
ileo-csecal  valve.  It  is  true  that  this  valve  may  become  insuffi- 
cient during  life,  and  may  permit  faecal  matter  to  regurgitate 
from  the  colon  into  the  lesser  bowel. 

This  insufficiency  may  be  met  with  in  great  distension  of 


8TEBG0BAGE0US    VOMITING-  301 

the  cseeum  and  ileum  associated  with  paralysis  of  the  parts- 
concerned  in  the  valve.  The  occurrence,  however,  of  this  in- 
sufficiency is  exceedingly  uncommon,  as  is  proved  by  repeated 
examinations  of  the  parts  after  death  from  stricture  of  the- 
colon.  In  cases  of  stricture  of  the  lower  colon  it  is  usual  to 
find  the  whole  colon  distended  with  accumulated  fseces.  The 
distended  gut  may  become  enormous,  and  so  efficient  is  the 
valve,  in  all  but  the  rarest  cases,  that  in  many  instances  death 
has  been  due  to  actual  rupture  of  the  over-dilated  cseeum. 
Indeed,  it  may  be  said  that  in  slowly- advancing  obstruction 
of  the  colon  the  large  intestine  will  burst  before  the  valve  will 
give  way. 

The  actual  production  of  stercoraceous  vomiting  may  be- 
explained  in  the  following  manner. 

Let  it  be  imagined  that  the  ileum  at  a  certain  spot  becomes 
occluded.  The  function  of  the  bowel  is  arrested  or,  at  least,, 
grossly  disturbed.  Fluid  accumulates  above  the  obstructed 
point.  It  decomposes.  If  any  movement  be  imparted  to  the 
bowel,  it  cannot  serve  to  force  the  contents  downwards,  and  it 
must  have  the  effect  of  propelling  them  towards  the  stomach. 
If  the  intestine  contracts  by  virtue  of  its  muscular  power,  or  if 
increasing  distension  in  adjacent  coils  causes  the  bowel  to  be 
pressed  upon,  it  can  only  empty  itself  in  one  direction,  i.e.^ 
towards  the  stomach. 

Dr.  Brintoh,  in  his  well-known  monograph,  amplifies  this 
explanation  in  the  following  way.  The  bowel  becomes  oc- 
cluded at  a  certain  point.  Above  that  point  the  contents  of 
the  tube  collect,  and  some  dilatation  of  the  bowel  from  dis- 
tension takes  place.  A  wave  of  peristaltic  movement  passing 
along  the  intestine  above  the  occluded  part  will  tend  to  induce 
two  distinct  currents  in  the  contents  of  the  tube,  in  the  place 
of  the  single  current  in  the  direction  of  the  rectum  which  is 
the  result  of  peristalsis  in  normal  circumstances.  One  of 
these  movements  is  in  the  downward  direction  and  concerns 
such  of  the  contents  as  are  nearer  to  the  wall  of  the  intestine. 
The  other  is  an  upward  movement  which  concerns  the  con- 
tents occupying  the  axial  part  of  the  bowel.  This  axial 
current,  in  the  upward  direction,  is  the  direct  result  of 
the  obstruction  offered  to  the  passage  of  matters  along  the 
intestine.  Dr.  Brinton  illustrates  the  double  current  by  the 
action  of  a  piston,  perforated  in  the  centre,  as  it  passes  along 
a  tube  closed  at  one  extremity  (Fig.  106).  He  further  pointed 
out  that  a  series  of  such  pistons  passing  down  the  tube  one 
after  the  other  would  tend  to  lengthen  indefinitely  the  upward 
axial  current  and  render  it  perfectly  continuous. 

Dr.  Brinton  also  showed  that  the  distended  segment' of 


302 


G'LMICAL    MANIFESTATION'S. 


intestine  immediately  above  the  obstruction  would  be  practi- 
cally unaffected  by  the  peristaltic  movements,  and  would  have 
the  effect  of  placing  the  starting  point  of  the  upward  axial  ■ 
movement  higher  and  higher  in  the  intestine  as  the  accumu- 
lation increased. 

'  This  latter  circumstance,  however,  is  by  no  means  necessary 
for  the  complete  demonstration  of  Dr.  Brinton's 
theory  of  the  emptying  of  the  intestinal  contents 
into  the  stomach  by  no  other  motor  power  than 
the  peristaltic  movements  of  the  bowel  itself.  As 
a  matter  of  fact,  however,  there  is  more  than  one 
factor  concerned  in  the  evacuation  upwards  of  the 
intestinal  contents  When  the  bowel  above  the 
occlusion  has  become  filled  by  gradual  accumula- 
tion of  its  contents,  its  degree  of  distension  may 
be  such  that  all  pressure  brought  to  bear  upon 
the  bowel  so  occupied  can  do  no  other  than  force 
the  contents  in  the  only  direction  in  which  they 
can  go,  viz.  towards  the  stomach.  This  pressure 
may  be  exercised  during  every  act  of  vomiting, 
I  every  contraction  of  the  diaphragm  or  of  the  ab- 
^1  !  dominal  muscles,  and  even  by  the  mutual  pres- 
sure that  the  distended  coils  would  exercise  the 
one  upon  the  other. 

In  some  cases  fgeculent  vomiting  of  a  more 

Fig.  106.       q^.  |ggg  undoubted  character  has  been  due  to  a 

fistulous  communication  between   the  colon  and 

the  upper  part  of  the  small  intestine,  as  occurred  in  a  case 

reported  by  Mr.  Shaw.'^ 

It  is  impossible  to  leave  this  subject  without  some  refer- 
ence to  the  question  of  antiperistalsis,  which  was  at  one  time 
accredited  with  being  the  cause  of  stercoraceous  vomiting. 
That  antiperistaltic  movements  occur  in  the  intestine  has  been 
placed  beyond  doubt  by  numerous  observers.  These  move- 
ments have  been  seen  also  in  cases  of  artificial  obstruction  of 
the  bowels  induced  in  animals.  There  is,  however,  little  evi- 
dence to  show  that  antiperistalsis  is  essential  for  the  propelling 
of  the  intestinal  contents  towards  the  stomach,  much  less  that 
it  is  the  main  cause  of  stercoraceous  vomiting.  These  move- 
ments, when  observed,  have  been  feeble,  imperfect,  and  irregu- 
lar, and  of  comparatively  little  significance  by  the  side  of  the 
tumultuous  peristaltic  movements  passing  in  the  usual 
direction. 

As  Dr.  Brinton  has  well  observed,  if  antiperistalsis  were 
the  cause  of  stercoraceous  vomiting,  then  would  one  expect  to 

*  Path.  Soc.  Trans.,  vol.  iv.,  p.  147. 


STERGOBAGEOUS    VOMITING.  303 

find  at  an  operation  the  gut  above  the  obstruction  empty  and 
contracted,  while  the  intestine  nearer  to  the  stomach  would 
be  in  a  state  of  distension.  It  is  needless  to  say  that  the 
reverse  is  what  is  found.  In  many  cases,  moreover,  metallic 
mercury,  and  other  substances  introduced  into  the  stomach 
before  death,  have  been  found  in  the  autopsy  to  have  traversed 
the  whole  length  of  the  intestine  as  far  as  the  obstruction,  in 
spite  of  severe  vomiting  during  life. 

The  following  series  of  experiments  upon  animals,  to  illus- 
trate the  production  of  peristaltic  movement,  may  be  briefly 
considered. 

Nothnagel^  showed  that  the  normal  intestinal  contents 
provoke  movement  in  the  bowel,  spreading  from  the  stomach 
to  the  anus,  but  that  violent  irritants  applied  to  the  gut 
produced  movement  in  the  opposite  direction.  When  the 
intestinal  wall  was  touched  with  a  soda  salt  or  stimulated 
by  a  faradic  current,  a  contraction  of  circular  fibres  followed, 
which  spread  towards  the  stomach  arid  only  feebly  towards 
the  anus. 

Llideritz  t  demonstrated  that  distension  of  the  gut  to 
the  maximum  produced  paralysis,  and  rendered  the  gut 
incapable  of  responding  to  any  stimulant — chemical,  mechan- 
ical, or  electrical. 

Hess:]:  introduced  a  light  rubber  ball  into  the  bowel,  and 
watched  its  movements  under  various  conditions.  Move- 
ments of  contraction  began  above  the  ball,  and  pushed  it 
downwards.  If  a  stimulant,  such  as  a  crystal  of  nitrate  of 
soda,  be  applied  to  the  bowel  above  the  ball  a  peristaltic 
wave  spreads  towards  the  stomach,  but  the  ball  does  not 
move.  A  like  stimulant  applied  to  the  gut  below  the  ball 
caused  a  peristaltic  wave  to  spread  towards  the  stomach,  and 
the  ball  to  move  upwards.  In  the  passage  of  a  foreign 
bod}^  along  the  intestine  contraction  of  the  gut  just  above 
the  substance  is  being  continually  produced.  It  is  indeed 
propelled  downwards  by  repeated  upward  spreading  com- 
motions. Hess  showed  that  interference  with  the  circulation 
of  the  gut  such  as  followed  ligature  of  a  mesenteric  artery 
or  the  circulation  of  dyspnoeic  blood  produced  peristalsis. 
The  quite  empty  bowel  keeps  at  rest. 

Bokai  §  states  that  the  most  sensitive  part  of  the  intes- 
tinal canal  is  the  duodenum  and  jejunum,  the  ileum  comes 
ne.^t  in  order,  then  the  rectum,  and  last  of  all  the  colon. 

*  Zeit.  klin.  Med.,  bd.  iv.,  heft,  iv.,  1882. 

f  Virchow's  Archiv,  1889,  bd.  18;  and  1890,  bd.  122. 

}  Deutsch.  Archiv  f.  klin.  Med.,  1887. 

^  Archiv  f.  exp.  Path.  u.  Pharm..  1887,  bd  23,  p.  209. 


204  GLlNiaAL    MANIFESTATIONS. 

4.  The  State  of  the  Bowels. — The  constipation  in  cases 
of  obstruction  of  the  bowels  depends,  of  course,  in  the  main 
upon  the  narrowing  or  occhision  of  the  hnnen  of  the 
intestine. 

It  may  depend  also  upon  paralysis  ot  a  segment  of  the 
intestine  without  mechanical  obstruction  in  the  intestine 
itself,  as  in  chronic  constipation,  in  great  distension  of  the 
bowel,  or  in  cases  associated  with  a  little  peritonitis.  It  is 
also  to  a  great  extent  due  to  reflex  nerve-action.  Thus,  in 
cases  of  acute  strangulation,  the  constipation  is  often  absolute 
from  the  very  commencement,  although  the  obstruction 
may  be  in  the  small  intestine,  and  much  fsecal  matter  be 
lodged  between  the  point  of  occlusion  and  the  anus.  Then, 
again,  constipation  is  very  usual  in  those  cases  of  partial 
obstruction  of  the  intestine  where  a  segment  of  the  bowel 
is  suddenly  and  severely  nipped.  This  is  well  observed,  as 
a  rule,  in  the  partial  enterocele  or  Richter's  hernia,  where 
only  a  part  of  the  circumference  of  the  bowel  is  involved 
in  the  strangulation. 

In  cases  of  acute  strangulation  it  is  not  infrequent,  early 
in  the  case,  for  the  part  of  the  bowel  below  the  obstruction 
to  be  emptied,  and  in  examples  where  some  catarrhal  action 
has  been  set  up  in  this  segment  of  the  bowel  the  patient 
may  present  the  evidences  of  diarrhoea. 

It  is  not  uncommon  in  cases  of  acute  obstruction  for  a 
stool  to  be  spontaneously  passed  just  before  death.  This 
may  be  derived  from  the  bowel  below  the  occlusion,  and 
may  be  due  to  certain  altered  nerve  conditions  associated 
with  impending  death,  or  the  stool  may  be  derived  from 
the  intestine  above  the  point  of  stoppage,  and  may  indicate 
the  yielding  of  the  obstruction  from  perforation  or  by  other 
spontaneous  means.  Or  the  occlusion  may  have  been  in- 
complete, and  the  nerve  conditions  that  maintained  the  con- 
stipation may  have  become  modified  as  death  approached. 

In  intussusception  there  is  a  form  of  diarrhoea,  and  a 
spurious  diarrhoea  may  persist  for  months  in  a  case  of 
stricture  low  down  in  the  colon.  This  species  of  diarrhoea 
is  the  outcome  of  catarrh  of  the  bowel  above  the  place  of 
stenosis. 

The  diagnostic  significance  of  the  altered  shape  of  the 
motions  passed  is  dealt  with  in  the  account  of  the  symptoms 
of  stricture  of  the  bowel  (page  394). 

5.  The  State  of  the  Abdomen. — Three  matters  will  be 
considered  under  this  heading,  viz.  visible  peristaltic  move- 
ments, meteorism,  and  abdominal  tumour. 

(i.)  Visible  eeristalxic.  movements   and  visible  coils  of 


VISIBLE   PERISTALTIC    MOVEMENTS.  305 

intestine  indicate  a  long-abiding,  partial  mechanical  obstruc- 
tion which  has  led  to  hypertrophy  of  the  bowel  above  it. 
This  feature  is,  therefore,  of  considerable  diagnostic  value. 

The  distinctness  with  which  the  intestinal  coils  are 
seen  when  in  movement  depends  mainly  upon  three  circum- 
stances :  upon  the  degree  of  emaciation  of  the  patient,  and 
the  consequent  thinness  of  the  abdominal  parietes;  upon 
the  hypertrophy  of  the  intestine  above  the  obstruction ;  and 
upon  the  extent  of  distension  of  the  hypertrophied  coils. 
It  will  be  evident  that  the  first  two  of  these  conditions  are 
especially  prone  to  be  associated  with  a  chronic  form  of 
obstruction. 

It  is  indeed  in  the  chronic  varieties  of  intestinal  obstruc- 
tion that  this  important  symptom  is  seen.  It  indicates  not 
only  that  there  is  a  long-abiding  obstacle  in  the  lumen  of 
the  bowel,  but  also  that  tliat  obstacle  only  partially  occludes 
the  intestinal  tube. 

The  bowel  becomes  hypertrophied  in  its  attempt  to  force 
material  through  the  narrowed  strait.  Its  muscular  tissue 
becomes  increased  as  does  that  of  the  wall  of  the  left  ventricle 
in  stenosis  of  the  aortic  orifice. 

The  hypertrophy  of  the  bowel  proceeds  but  slowly,  and 
some  time — certainly  many  weeks — must  elapse  before  the 
increase  in  the  intestinal  coats  can  reach  a  degree  sufficient 
to  render  the  coil  conspicuous. 

Post-mortem  examination  shows  that  in  quite  chronic 
cases  the  hypertrophy  can  reach  a  high  degree  and  the  wall  of 
the  bowel  become  enormously  thickened.  The  most  marked 
examples  of  this  are  afforded  by  the  colon,  inasmuch  as 
instances  of  stenosis  of  the  gut  are  most  common  in 
the  lower  colon,  and  are  most  usually  of  a  chronic  type. 
Stenoses  in  the  lesser  intestine  are,  comparatively  speaking, 
infrequent  and  follow  a  less  rapid  course  in  the  majority  of 
instances. 

In  a  well-marked  case  the  hypertrophied  coils  can  be  seen 
moving  beneath  the  thinned  parietes.  Sometimes  one  indi- 
vidual coil — possibly  the  transverse  colon — can  be  seen  to  stand 
up  in  relief  and  then  subside.  When  it  subsides,  it  indicates 
that  the  muscular  tunics  of  the  bowel  are  contracted ;  when  it 
becomes  prominent,  it  indicates  that  those  tunics  are  relaxed, 
and  that  the  enlarged  bowel  is  occupied  by  gas.  The  promi- 
nent coil  is  nearly  always  tympanitic  on  percussion. 

These  movements  in  the  bowel  are  associated  with  colicky 
pain  and  often  Avith  gurgling  and  bubbling  sounds. 

In  other  instances  several  coils  can  be  seen,  but  not 
necessarily  at  the  same  time.  The  movement  beneath  the 
u 


mn  CLINICAL    MANIFESTATIOXS. 

parietes  has  been  compared  to  that  of  a  snake,  but  it  is  a 
snake  that  moves  slowly  and  in  disconnected  segments. 

A.  coil  will  rise  up  slowly  under  the  parietes,  exhibit 
some  undulatory  or  twisting  movement,  and  then  vanish. 
Pain  is  felt  when  the  coil  is  shrinking  or  contracting,  not  when 
it  is  becoming  prominent  or  dilated. 

When  the  obstruction  in  the  bowel  becomes  complete  the 
movements  of  visible  coils  cease. 

Such  movements  are  not  seen  in  cases  of  acute  ol»struc- 
tion,  or  only  in  exceptional  instances  of  that  trouble 
attended  with  severe  colic,  and  in  patients  with  attenuated 
parietes. 

Certain  questions  in  connection  with  the  position  of  visibly 
moving  coils  are  discussed  on  page  315. 

It  remains  to  be  asked  if  the  existence  of  visible  intestinal 
coils  in  movement  beneath  the  parietes  is  positive  evidence 
that  the  bowel  is  the  seat  of  a  partial  mechanical  obstruction. 
The  answer  to  this  question  is  that,  in  the  very  great  majority 
of  the  examples,  the  symptom  mentioned  is  positive  evidence 
of  such  obstruction.  The  exceptions  are  few,  and  consist 
mostly  of  cases  in  which  the  patient  is  emaciated  and  the 
abdominal  walls  are  thin.  In  individuals  with  very  thin  and 
very  lax  abdominal  walls,  as  seen  in  emaciated  women  who  may 
have  had  several  children,  the  outline  of  coils  of  bowel  when 
distended  may  be  defined  beneath  the  parietes,  and  under  the 
influence  of  stimuli  some  feeble  movement  may  be  seen  in 
them.  It  is  needless  to  say  that  normal  coils  of  bowel  can 
also  be  seen  in  faint  movement  through  the  attenuated  walls 
of  large  ventral  or  umbilical  hernise,  but  such  instances  as 
these  can  hardly  be  ranked  as  exceptions  to  the  rule  just  quoted. 

I  have  only  met  with  two  instances  in  Avhich  visible  peri- 
staltic movements  Avere  to  be  seen  through  normal  abdominal 
walls  in  patients  who  exhibited  no  mechanical  obstruction  in 
any  part  of  the  intestine.  They  were  both  cases  of  the  same 
type.  The  patients  were  females,  one  was  about  sixty  years  of 
age  and  had  had  several  children,  the  other  was  thirty  and 
unmarried.  Both  Avere  very  thin  and  intensely  neurotic 
subjects.  They  suffered  from  obstinate  constipation,  with 
considerable  flatulent  distension  of  the  abdomen,  attended 
Avith  little  pain  and  with  no  vomiting.  A  Aveek  Avould  some- 
times elapse  before  the  bowels  Avould  respond  to  the  measures 
used  to  act  upon  them.  Both  patients  exhibited  bizarre 
nervous  phenomena  of  an  extreme  type,  and  both  Avere  bed- 
ridden. 

In  both  cases  I  made  a  free  exploratory  incision,  and 
discovered  that  the  flatulent  distension  Avas  limited  to  the 


METEORfSM.  307 

colon,  which  was  not  hypertrophied,  and  that  there  was  no 
jnechanical  obstruction  of  any  kind.  In  one  patient  I  made 
a  minute  temporary  stoma  in  the  sigmoid  flexure  to  allow 
gas  to  escape.  It  was  closed  after  a  few  months.  Both 
patients  were  relieved  of  their  abdominal  s3anptoms.  The 
point  of  interest  is  that  in  these  cases  coils  of  intestine  in 
movement  were  visible,  and  the  movements  were  attended 
with  some  colic. 

In  dealing  with  cases  of  obstruction  due  to  the  pressure 
of  a  tumour  outside  the  bowel,  I  have  alluded  to  two 
instances  of  obstruction  due  to  retroflexion  of  the  uterus, 
in  which  this  symptom  of  visible  coils  was  present,  but  in 
a  modified  condition  (page  273). 

(ii.)  Meteokism. — It  was  at  one  time  assumed  that  the 
distension  of  the  belly  which  takes  place  in  intestinal 
obstruction  was  due  to  mere  accumulation  of  the  intestinal 
contents  and  of  flatus  above  the  point  of  obstruction.  The 
flatus — which  is  the  essential  factor  in  meteorism — was 
stated  to  be  due  partly  to  mere  accumulation  and  partly 
to  an  abnormal  production  of  gas  as  a  result  of  unusual 
decomposition.  It  was  therefore  inferred  that  the  more 
complete  the  obstruction  the  more  marked  was  the  tyni- 
panites,  and  that  the  greatest  degree  of  meteorism  was 
to  be  met  with  when  the  bowel  was  occluded  low  down. 
Indeed,  the  necessary  conclusion  followed  that  the  further 
the  obstacle  was  from  the  stomach  the  greater  was  the 
degree  of  meteorism. 

Extended  clinical  experience  has,  however,  shown  that 
this  explanation,  although  containing  a  large  element  of 
truth,  is  neither  satisfactory  nor  sufficient. 

Mere  accumulation  of  the  bowel  contents  is  by  no  means 
the  only  factor  in  the  production  of  meteorism.  That 
symptom  is,  on  the  contrary,  largely  influenced  by  dis- 
turbances of  the  muscular  and  nervous  apparatus  of  the 
bowel,  and  by  disorders  in  the  circulation  of  the  gut. 

It  is  needless  to  sa}^  that  advanced  meteorism  may  exist 
quite  independentl}^  of  any  intestinal  obstruction.  The  bowel 
when  paralysed  from  any  cause  is  in  a  state  of  tympanites, 
and  the  tympanitic  abdomen  in  peritonitis  depends  upon  no 
mechanical  obstruction. 

In  not  a  few  cases  tympanitic  distension  of  the  bowel 
appears  to  be  largely  or  solely  of  nerve  origin.  There  is 
no  doubt  but  that  many  examples  of  so-called  'flatulent 
dyspepsia  should  be  classed  with  nervous  diseases. 

A  certain  phase  of  this  subject  has  been  dealt  with  in 
treating  upon  idiopathic  dilatation  of  the  colon  (page  242). 


-308  CLINICAL   MANIFE^STATIONS. 

The  question  of  the  production  of  meteorisni  in  intestinal 
obstruction  can  be  further  illustrated  by  certain  experimerits 
>vhich  have  been  made  upon  animals, 

The  most  complete  series  of  experiments  in  connection 
with  this  subject  are  those  made  by  Kader,*  and  a  summary 
of  the  results  he  obtained  will  be  found  on  page  13. 

Meteorism  is  most  marked  and  is  earliest  seen  when  the 
colon  is  obstructed.  In  no  form  of  intestinal  obstruction  is 
meteorism  at  once  more  sudden  and  more  severe  than  in 
volvulus  of  the  sigmoid  flexure. 

In  occlusion  of  the  upper  jejunum  the  distension  of  the 
abdomen  may  be  confined  to  the  region  of  the  stomach. 
When  the  small  intestines  are  distended  and  the  colon  is 
empty,  the  median  parts  of  the  belly  are  protuberant.  When 
the  colon  is  the  part  distended,  its  anatomical  disposition  is 
often  very  clearly  to  be  made  out  through  the  parietes.  It 
is  unsafe,  however,  to  base  a  diagnosis  as  to  the  seat  of  the 
obstruction  from  the  apparent  situation  of  distended  coils. 

This  matter  is  further  dealt  with  on  page  315. 

The  degree  of  meteorism  in  any  given  case  varies  from 
time  to  time.  It  is  not  so  much  reduced  by  vomiting  or 
even  by  diarrhoea  as  may  be  supposed.  It  is  very  often 
lessened  by  strychnia  administered  hypodermically.  It  is 
in  many  instances  increased  by  morphia. 

(iii.)  An  abdominal  tumour  may  be  felt  in  the  following 
cases : — Intussusception,  faecal  accumulation,  cancer,  certain 
neoplasms,  and  in  some  cases  of  obstruction  by  foreign  bodies, 

A  number  of  coils  of  small  intestine,  matted  together  by 
adhesions,  have  formed  a  species  of  tumour,  and  a  localised 
dulness  on  percussion  has  been  caused  by  collapsed  coils 
of  the  lesser  bowel  which  have  become  grouped  together 
below  an  obstruction.  Such  empty  coils  may  occasionally 
be  felt  by  the  finger  on  a  rectal  examination,  and  be  mis- 
taken for  a  solid  substance. 

6.  The  diminished  amount  of  urine  passed  in  many 
of  the  acute  cases  does  not  depend  upon  the  seat  of  the 
obstruction,  as  once  was  urged,  but  upon  its  acuteness  and 
the  degree  of  the  impression  made  upon  the  nervous  system. 
It  is  rather  one  of  the  symptoms  of  collapse,  and  varies  with 
the  extent  of  the  collapse  and  the  severity  of  the  pain,  In 
these  cases  a  marked  increase  in  the  amount  of  urine  passed 
attends  the  administration  of  a  full  dose  of  opium. 

7.  Indicanuria. — Indican  is  met  with  in  the  urine  in 
certain  forms  of  intestinal  obstruction,  and  especially  in  acute 
obstruction  involving  the  small  intestine. 

*  Deutsch.  Zeitschrift  fiir  Chirurgie,   1891,  p.  57, 


INDICANURTA.  309 

Skatol  and  indol  compounds  and  their  allies  in  the 
form  of  aromatic  sulphates  are  stated  to  be  more  or  less 
the  products  of  intestinal  putrefaction.  Dr.  Rose  Bradford 
has  pointed  out  that  these  curious  products  appear  to  be 
excreted  b}'-  the  kidney  rather  than  by  the  fseces. 

Indican  belongs  to  this  group,  and  is  in  chemical  language 
indoxyl  potassic  sulphate. 

Indican  is  formed  in  the  alimentary  canal  from  indol,  and 
indicanuria  is  especially  met  with  in  cases  attended  by 
intestinal  putrefaction. 

Indicanuria  is  found  in  acute  and  chronic  intestinal 
obstruction,  in  peritonitis,  and  in  several  other  conditions, 
such  as  suppuration  of   the  pleural  cavity. 

Its  value  as  a  means  of  differential  diagnosis  between 
obstructions  in  the  colon  and  in  the  small  intestine  is  alluded 
to  on  page  320. 

Indican  in  the  urine  can  be  detected  by  the  following 
methods : — 

To  the  specimen  of  urine  about  one-fourth  or  one-third  of 
its  volume  of  hydrochloric  acid  is  added,  together  with  some 
calcium  hydrochlorate.  The  mixture  is  allowed  to  stand  for 
twentj'-four  hours,  and  then  a  characteristic  blue  scum  is 
observed  on  the  surface. 

Macmunn's  method  is  as  follows : — ^The  urine  is  boiled 
with  an  equal  measure  of  hydrochloric  acid  and  a  few  drops  or 
nitric  acid,  is  cooled  and  is  then  agitated  with  chloroform. 
The  chloroform  is  coloured  violet  if  indican  be  present  in 
any  quantity. 

In  a  paper  b}^  Mr.  Pearce  Gould  on  a  case  of  acute 
intestinal  obstruction,  an  admirable  coloured  illustration  is 
given  of  the  test  tube  effects  produced  by  indican  in  urine.* 

*  Trans.  Clin.  Soc.  Lond.,  vol.  xxxi.,  1898,  p.  47.  See  also  Neubauer  and 
Yogel ;  Analyse  des  Hams,  p.  556,  Wiesbaden,  1898 ;  and  Alfred  Allen ; 
Chemistry  of  Urine,  p.  200,  London,  1895. 


310 


CHAPTER    III. 

THE    SYMPTOMS    AS    MODIFIED    BY    THE    POSITION    OF 
THE    OBSTEUCTIOX. 

The  matters  to  be  considered  under  this  headmg  practi- 
cally resolve  tlieiuselves  into  an  examination  of  the  clinical 
differences  between  obstruction  situated  in  the  small  and  in 
the  large  intestines. 

The  differences  between  cases  of  stoppage  situated  in  these 
two  segments  of  the  bowel  are  not  Tery  rigidly  marked,  and 
can  only  be  given  in  broad  outline.  There  are  no  distinctions 
which  may  be  considered  as  absolute  and  invariable. 

It  is  true  that  the  larger  number  of  the  cases  of  obstru<"- 
tion  of  the  colon  tend  to  assume  a  chronic  course,  while  the 
larger  number  of  cases  .situated  in  the  smaU.  intestine  tend  to 
take  on  an  acute  character.  Thus,  a  ver}*  slight  observation 
of  a  series  of  instances  of  intestinal  occlusion  may  appear  ro 
demonstrate  at  once  conspicuous  differences  between  an  ob- 
struction in  the  large  intestine  and  one  in  the  small 

When,  however,  cases  of  hke  degree  are  compared,  when 
cases  of  chronic  obstruction  in  the  colon  are  compared  with 
chronic  cases  involving  the  lesser  bowel,  and  when  acute 
obstructions  in  the  one  segment  are  compared  with  acute 
obstructions  in  the  other,  it  will  be  found  that  the  great  bulk 
of  the  fancied  distinctions  entirely  disappears.  It  is  usually 
assumed  that  obstructions  of  the  colon,  when  compared  with 
those  of  the  smaller  intestine,  are  apt  to  present  a  tardy 
course,  to  be  associated  with  comparatively  httle  pain,  and 
with  a  slighter  degree  of  constitutional  disturbance,  and  to  be 
attended  by  vomiting  which  appears  late  and  is  much  less 
profuse  and  distressing.  This  will  be  true  as  regards  the  more 
common  forms  of  obstruction  of  the  colon,  but  it  does  not 
apply  to  the  acute  forms.  A  case  of  volvulus  of  the  sigmoid 
flexure    mav    present    symptoms    as    violent    and    as    rapidly 


IXFLCEXCE    OF   POSITIOy.  311 

developed  as  any  met  with,  in  cases  of  acute  strangulation  of 
the  small  intestine. 

Indeed,  the  more  extensiye  the  comparison  between  ob- 
structions in  the  colon  and  obstructions  in  the  small  intestine, 
the  more  distinctly  is  it  eyident  that  the  clinical  distinctions 
are  not  emphatic,  and  that  they  depend  more  upon  the  nature 
of  the  occlusion  than  upon  its  situation. 

Still,  however,  after  these  reservations  have  been  made,  it 
will  be  found  that  there  are  a  few  features  which  may  be 
made  a  basis  for  comparison  in  cases  of  a  fairly  equal  degree 
of  severity,  although  even  then  it  is  desirable  that  their  indi- 
vidual value  should  not  be  over-estimated  in  diagnosis. 

In  comparing  obstructions  of  the  colon  with  those  ot*  the 
lesser  bowel,  it  is  desirable,  in  the  tirst  place,  to  note  the 
physiological  differences  between  these  two  segments  of  the 
ahmentary  canal. 

The  small  intestine  is  active  and  veiy  vigorously  con- 
cerned in  the  business  of  the  organism:  it  takes  a  large 
and  important  share  in  the  process  of  digestion :  its  walls 
are  muscular ;  its  blood-vessels  are  numerous,  and  its  nerves, 
having  origin  from  the  superior  mesenteric-  plexus,  are  brought 
into  very  direct  connection  with  the  great  nerve-centres  of 
the  abdomen.  So  far  as  response  to  stimuli  is  concerned, 
the  lesser  bowel  is  shown  to  be  sensitive  and  irritable. 

On  the  other  hand,  the  function  of  the  large  intestine  is  to 
a  great  extent  passive.  The  part  it  plays  in  digestion  is  quite 
unimportant,  it  serves  as  a  receptacle  for  the  contents  of 
the  bowel,  so  that  long  intervals  may  elapse  between 
the  evacuation  of  these  contents.  In  one  sense,  the  iieo- 
ctecal  valve  may  be  regarded  as  a  kind  of  internal  anus. 
xA.n  accumulation  of  matter  in  the  small  intestine  soon  causes 
distress,  but  such  accumulations  in  the  colon  are,  within  cer- 
tain limits,  normal.  The  large  intestine  is  not  so  muscular  as 
the  small,  nor  so  freely  supphed  with  blood.  Its  nerves  also 
are  in  great  part  derived  from  the  inferior  mesenteric  plexus, 
and  have  thus  a  comparatively  indirect  connection  with  the 
principal  abdominal  nerve  centres.  Such  parts  of  the  colon 
as  are  supphed  by  the  superior  mesenteric  plexus  are 
supplied  by  the  filaments  of  that  plexus  which  are  most 
remote  from  the  main  source  of  origin  of  the  nerves.  It  is 
said  also  that  the  intraparietal  nerve  j)lexuses  of  the  intestine 
are  more  elaborately  developed  in  the  small  than  in  the  large 
intestine.  Lastly,  the  colon  has  a  less  extensive  connection 
with  the  peritoneum,  and  has  therefore  a  less  elaborate  nerve 
relation  and  a  less  extensive  area  exposed  to  peritoneal 
infection. 


312  DIAGNOSIS    OF   SEA  T  OF    OBSTRUC TION. 

There  is  no  evidence  to  show  that  there  is  any  consider- 
able anatomical  or  physiological  difference  between  the  serous 
membrane  as  it  covers  the  small  intestine  and  as  it  covers  the 
colon.  When,  in  two  cases  of  obstruction  (one  in  the  small 
gut  and  one  in  the  large),  an  equal  amount  of  peritoneum  is 
damaged  to  an  equal  extent,  it  may  be  anticipated  that  the 
nerve  disturbances  arising  from  that  lesion  will  not  be  dis- 
similar. And  in  connection  with  this  matter  it  is  noticeable 
that  the  form  of  obstruction  of  the  colon  which  most  closely 
resembles  acute  strangulation  of  the  small  intestine  is  vol- 
vulus of  the  sigmoid  flexure,  where,  as  is  well  known,  a  very 
extensive  surface  of  peritoneum  is  concerned. 

In  these  cases  it  would  appear  that  the  greater  surface  of 
serous  membrane  involved  in  the  volvulus,  as  compared  with 
the  amount  usually  implicated  in  small-gut  strangulations, 
has  been  able  to  overbalance  the  anatomical  differences 
between  the  large  and  small  intestine  as  regards  their  ability 
to  form  the  basis  of  symptoms. 

Such  comparison  as  can  be  made  between  obstructions 
of  like  degree  involving  the  lesser  bowel  on  the  one  hand 
and  the  colon  on  the  other  is  summed  up  in  the  following 
analysis  of  the  leading  symptoms. 

Pain. — When  the  small  intestine  is  concerned,  the  pain 
usually  appears  earlier,  is  more  pronounced,  more  abiding, 
and  more  severe.  The  localisation  of  the  pain  as  an  element 
in  the  differential  diagnosis  is  of  very  little  use. 

Vomiting. — In  obstruction  of  the  small  intes.tine,  as  com- 
pared with  that  of  the  large,  this  symptom  appears  earlier,  is 
more  distressing,  and  is  more  persistent.  In  the  obstructions 
of  the  lesser  bowel  the  vomited  matters  are  often  copious, 
are  apt  to  be  influenced  by  food,  and  more  readily  become 
stercoraceous  than  is  the  case  when  the  stoppage  is  in  the 
colon.  It  becomes  stercoraceous,  on  an  average,  about  the 
fifth  day  in  small-gut  obstruction.  Vomiting  due  to  trouble 
in  the  large  intestine  may  become  irregular,  may  cease  for  a 
while,  and  may  be  comparatively  slight.  It  tends  to  appear 
late,  to  be  scanty,  and  is  rarely  stercoraceous  until  after  a 
considerable  interval.  In  obstruction  of  the  small  intestine 
the  vomiting  often  gives  a  degree  of  relief  which  is  not  noticed 
ill  the  vomiting  attending  the  colic  obstruction.  In  any  case 
the  relief,  if  any,  is  onl}^  temporary. 

Constitutional  Disturbance.— This  is,  other  things  being 
equal,  more  marked  in  small-gut  obstructions  than  in  those 
of  the  colon.  There  is,  in  the  former,  a  greater  tendency  to 
severe  collapse,  and  consequently  a  more  frequent  appearance 
of  the  various  phenomena  connected  with  shock 


METEORISM. 


313 


Meteorism.^-Meteorisin,  as  expressed  by  mere  distension 
of  the  abdomen,  is  of  no  diag'nostic  value  in  acute  obstruction 
in  the  way  of  indicating  whether  the  obstacle  be  in  the  small 
or  the  large  intestine. 

Speaking  in  general  terms,  it  may  be  said  that  in  acute 


Fio.  107. 


-Dilatation  of  the  Colon  above  a  Stricture  of  the  Splenic  Flexure. 
{After  No  th  nag  el.) 


obstruction  the  distension  is  less  when  the  lesser  bowel  is 
involved  than  it  is  when  the  colon  is  concerned. 

In  chronic  obstruction  also,  the  highest  degree  of  dis- 
tension of  the  belly  is  met  with  in  examples  of  stenosis  in  the 
lower  parts  of  the  colon. 

When  the  lower  part  of  the  small  intestine  is  obstructed, 
the  meteorism  first  shows  itself,  and  remains  for  a  while  most 
marked,  in  the  hypogastric,  epigastric,  and  umbilical  regions. 
In  typical  cases  the  abdomen  presents  the  appearance  of  a  six 
months'  pregnancy,  and  the  flanks  and  iliac  fossae  are  de- 
pressed. This  symptom,  however,  is  of  no  great  value,  for  the 
appearance  may  be  almost  exactly  imitated  by  a  distension  of 
the  sigmoid  flexure,  when  that  part  of  the  gut  forms  a  large 
coil,  which  projects  towards  the  middle  line  of  the  abdomen. 

The   distended   sigmoid   flexure   may    stretch   across    the 


314 


DIAGNOSIS    OF   SEAT    OF   OBSTRUCTION: 


ihe  right 


lobe  of 


Avhole  abdomen,  from  the  left  iliac  fossa  to 
the  liver. 

In  the  matter  of  the  rapidity  with  which  meteorism  ma}"" 
advance,  the  most  striking  example  is  afforded  by  volvulus  of 
the  sigmoid  flexure. 

Nothnagel  states  that  in  stenosis  of  the  colon,  percussion 
of  the  back,  in  the  upper  lumbar  region,  often  yields  a  loud 
deep  tympanitic  note  which  will  be  noticed  on  both  sides  of  the 

body    if     the    sigmoid 
1^'  '  ^    flexure  be  involved,  and 

^"  1    on  the  right  side  only 

if  the  obstructibn  be  in 
the  transverse  colon. 
Percussion  in  these 
regions  in  normal  sub- 
jects produces  a  more 
or  less  dull  note. 

Much  has  been 
Avritten  about  the  diag- 
nostic value  of  disten- 
sion of  the  flanks  in 
indicating  whether  the 
obstruction  is  situated 
in  the  colon  or  in  the 
lesser  bowel.  In  acute 
obstruction  this  symp- 
tom is  of  no  diagnostic 
value  whatever.  In 
chronic  obstruction  it 
is  of  very  little  practical 
use.  If  there  be  an 
obstruction  in  the  large 
intestine  so  that  either  the  ascending  or  the  descending  colon, 
or  both,  are  sufficiently  dilated  to  distend  the  flank,  then  the 
distended  and  hypertrophied  coils  will  be  so  far  evident 
that  the  symptom  apparent  in  the  flank  is  per  se  of  no 
signiflcance. 

I  have  seen  the  flanks  distended  in  a  case  in  which  the  ob- 
struction concerned  the  ileum  and  Nothnagel  mentions  an 
instance  in  which  distension  of  the  flanks,  and  fulness  of  the 
upper  part  of  the  abdomen  were  met  with  in  a  case  of  steno- 
sis of  the  jejunum. 

The  fulness  of  the  flanks  is,  moreover,  much  influenced  by 
.  the  posture  of  the  body,  by  the  amount  of  fat  in  the  tissues, 
and  by  the  firmness  of  the  muscles  on  the  one  hand,  or  their 
laxity  on  the  other. 


"^K, 


Fig.  108. — Dilatation  of  the  Sigmoid  Flexure 
above  a  Stricture  at  the  lower  end  of  the 
Flexure. 


VISIBLE    COILS    IN   MOVEMENT. 


315 


Visible  Coils  of  Intestine. — In  cases  of  chronic  obstruc- 
tion it  is  usual,  after  a  while,  for  the  hypertrophied  bowel 
above  the  stenosis  to  become  visible  through  the  probably 
attenuated  parietes,  and  to  be,  moreover,  seen  in  movement. 

It  is  obvious  that  much  importance  must  attach  to  the 


-fl 


Fio.  109. 


-Dilatation  of  the  Colon  and  small  Intestine  above  a  Stricture  of  the 
Siomoid  Flexure. 


recognition  of  the  visible  coil  when  the  question  of  the 
locality  of  the  obstruction  arises. 

It  is  not  so  easy  to  identify  these  dilated  coils  as  may 
be  supposed. 

The  dilated  loops  are  more  often  segments  of  the  colon 
than  of  the  small  intestine. 

The  small  intestine  above  an  obstruction  may  become 
enormously  increased  in  size,  but  coils  which  can  be  appro- 
priately called  gigantic  are  probably  alwaj's  portions  of  the 
colon. 

Now  and  then,  the  degree  of  mobility  of  the  dilated  coil 
may  be  of  service  in  defining  its  locality. 

The  best  rule  in  attempting  to  identify  a  particular  loop 
of  bowel,  wlien  seen  through  the  parietes,  is  to  ascribe  it  to 
that  part  of  the  intestinal  canal  which  would  normally  occupy 


316 


DIAGNOSIS   OF  SEAT  OF  OBSTliUGTION. 


the  position  of  the  loop  under  notice.  The  distended  coil, 
which  is  most  readily  recognised,  is  the  transverse  colon  {see 
Fig.  107).  When  of  large  size,  its  curved  outline  is  very 
characteristic. 

The  sigmoid  flexure  also  may  form  a  loop  which  is  not 
difficult  to  identify.  This  especially  is  the  case  when  the  loop 
has  extended  across  the  abdomen  to  the  right  hypochondriac 

region  {see  Fig.  108). 
It  is  to  be  remembered 
that  the  much  dilated 
transverse  colon  or 
sigmoid  flexure  may 
entirely  overlie  the 
small  intestines. 

The  distended  colic 
loop  is  often  consider- 
ably deformed. 

In  Figs.  109  and 
110  are  shown  ex- 
amples of  distension 
of  both  the  colon  and 
the  ileum,  and  in 
Fig.  Ill  is  shown  an 
example  of  visible  coils 
belonging  to  the  lesser 
bowel  only. 

In  watching  move- 
ments    in     the     dis- 
tended   coils,   it    will 
be  noticed  that  peri- 
staltic movements  are  slower  in  the  colon  than  in  the  small 
intestine. 

The  movements  in  a  dilated  and  hypertrophied  stomach 
are,  when  once  seen,  readily  recognised  from  like  movements 
in  dilated  intestines.  The  peristaltic  waves  which  pass  over 
the  enlarged  stomach  are  more  or  less  limited  to  the  left 
hypochondrium,  and  have  always  appeared  to  me  to  pass 
somewhat  obliquely  downwards  and  to  the  left. 

In  a  well-marked  case  of  movement  in  the  wall  of  a  hyper- 
trophied and  dilated  stomach  the  following  appearance  is  pre- 
sented. A  globular  swelling  emerges  from  under  the  left  ribs 
and  moves  slowly,  like  a  wave,  from  left  to  right.  Its  course 
is  a  little  oblique  in  a  downward  direction.  It  finall}"  vanishes 
under  the  right  ribs,  becoming  less  prominent  and  flatter 
before  it  disappears.  AVhen  in  the  middle  of  its  course,  it 
may  appear  as  a  well-rounded  globular,  swelling  the  size  of 


Fig.  110. — Dilatation  of  the  Ascending  Colon  and 
Ileum  above  a  Stricture  at  the  Hepatic  Flexure 
of  the  Colon.     {After  Nothnagel.) 


ENKMATA    2xV   DTAGNOSIS. 


317 


% 


a  foetal  head,  with  a  groove  in  front  of  it  and  another  behind 
it.  Before  one  wave  has  vanished  on  the  right  side  another 
swelhng  comes  into  view  from  under  the  left  ribs. 

If  the  pylorus  be  depressed  downwards,  the  movement  of 
the  wave  is  still  more  and 
more   oblique,    and   the    |' 
right  ribs  arenotreached. 

In  one  case  under  my 
observation  the  move- 
ment of  the  w^ave 
appeared  to  be  from 
right  to  left,  an  appear- 
ance which  was  no  doubt 
illusory. 

Fig.  112  shows  the 
"  organ-pipe  "  arrange- 
ment of  the  small  intes- 
tine, which,  according 
to  Nothnagel,  is  only 
met  with  in  cases  of 
extensive  peritoneal  ad- 
hesions. I  have  only 
seen  it  in  association 
with  old  tuberculous 
peritonitis. 

Some  diagnostic 
value  may  attach  to  tho 
recognition  of  the  point 
where  peristaltic  move- 
ment ends  among  the 
coils,  which  are  visible 
through  the  parietes. 

Enemata A   great   deal   has    been    written    by    various 

authors  upon  the  value  of  enemata  as  a  means  of  diagnosing 
the  seat  of  the  obstruction.  The  feature  in  this  niethod  con- 
sists in  a  comparative  estimation  of  the  amount  of  water  that 
can  be  held  bj''  certain  segments  of  the  bowel.  Thus,  elaborate 
statements  have  been  made  to  the  effect  that  if  a  certain 
amount  of  water  can  be  readily  injected,  then  the  obstruction 
must  be  in  the  sigmoid  flexure;  if  a  certain  additional  quantity 
can  be  introduced,  then  the  stoppage  must  be  in  the  descend- 
ing colon  ;  and,  iinally,  if  a  certain  number  of  ounces  or  pints 
can  be  received,  then  the  whole  of  the  large  intestine  must  be 
occupied  and  the  occlusion  must  be  situated  in  the  small 
bowel.  Dr.  Brinton,  for  example,  has  given  very  detailed 
instructions   upon    this   head.      The   statements  are   usually 


Fig.  111. — Dilatation  of  Coils  of  small  Intestine 
above  an  Obstrnction  in  the  lower  Ileum. 


318 


DIAGNOSIS    OF   SEAT    OF   OBSTRUCTION. 


based  upon  experiments  made  upon  the  cadaver  with  refer- 
ence to  the  actual  amount  of  fluid  that  various  segments  of 
the  colon  can  accommodate. 

For  diagnostic  purposes,  this  method  is,  I  venture  to 
think,  absolutely  useless.  In  the  first  place,  observations 
made  upon  the  cadaver,  where  the  parts  are  relaxed  and 
where  muscular  action  has  ceased,  are  not  likely  to  be 
identical   with   those   made   upon    the   living  subject.     The 

method,  moreover,  does 
not  take  into  consideration 
the  condition  of  the  bowel 
below  the  obstruction. 
This  part  of  the  tube  may 
be  dilated  or  contracted^ 
may  respond  vigorously  to 
certain  forms  of  irritation 
or  remain  absolutely  inert. 
The  rectum  may  be  con- 
tracted or  filled  with  fseces 
or  ballooned.  Then,  again, 
as  Dr.  Hilton  Fagge  has 
pointed  out,  there  are  cer- 
tain strictures,  especially 
those  associated  with  some 
bending  of  the  gut  or  with 
a  valvular  arrangement  of 
the     mucous     membrane 


mucous 
above  the  stenosed  part, 
through  which  water  may 
be  injected  from  below, 
Avhile  fluids  above  the 
stricture  are  unable  to  And 
a  way  to  escape.  I  have  myself  in  many  cases  had  an 
opportunity  of  verifying  the  fallacies  in  this  reputed  method 
of  diagnosis,  and  many  published  cases  serve  also  to  illus- 
trate these  errors.  As  an  example,  I  may  cite  one  instance 
of  stricture  of  the  sigmoid  flexure  where  over  three  pints  of 
water  were  introduced  by  an  enema  and  Avere  retained  for 
twenty-five  minutes.  This  large  quantity  of  fluid  must  have 
been  accommodated  in  the  rectum,  since  the  autopsy  revealed 
that  none  had  passed  beyond  the  stricture^ 

The  Passage  of  the  Long-  Tube— In  this  method  a  flexible 
tube  or  sound  is  passed  into  the  rectum,  and  an  attempt  is 
made  to  diagnose  the  seat  of  the  obstruction  by  noting  to 
what  distance  the  tube  can  be  introduced.     This  procedure 

*  Path,  8oc.  Trans  ,  vol.  vii.,  p.  207. 


Fig.  112. — Dilated  Coils  of  small  lutestiiie. 
' '  Organ-pipe  ' '  arrangement.  ( F^-om  a  case 
of  chronic  tuberculous  peritonitis  with  adhe- 
sions.) 


USE    OF    THE    LONG    TUBE.  319 

applies  mainly  to  stenosis  of  the  lower  part  of  the  colon.  As 
a  means  of  diagnosis,  it  is,  I  believe,  entirely  valueless.  In 
some  cases  the  somid  has  lodged  early  in  its  career  against  a 
fold  of  mucous  membrane,  and  the  diagnosis  of  an  obstruction 
low  down  in  the  bowel  has  been  in  consequence  made.  In 
other  instances,  in  stricture  of  the  termination  of  the  sigmoid 
flexure,  the  tube  has  reached  the  upper  extremity  of  the 
rectum,  and  has  then  turned  upon  itself,  or  become  coiled  up 
in  the  rectal  ampulla,  until  so  much  has  been  introduced  that 
the  whole  of  the  colon  downwards  from  the  splenic  flexure 
has  been  diagnosed  to  be  free  from  obstruction.  I  have  good 
reasons  for  doubting  if  these  rectal  sounds  ever  go  beyond  the 
sigmoid  flexure.  This  impression  is  fully  confirmed  by  experi- 
ments I  have  made  upon  the  dead  body.  If  the  segment  of 
the  colon  that  forms  the  sigmoid  flexure  and  the  free  part  of 
the  rectum  be  uncoiled,  it  will  appear  in  the  form  of  a  large 
loop  of  intestine,  extending  from  the  psoas  muscle  to  the  spot 
where  the  rectum  becomes  fixed  opposite  about  the  middle  of 
the  sacrum.  This  loop  has  the  outline  of  a  capital  omega, 
and  is  usually  provided  by  an  extensive  mesocolon.  Such  is 
occasionally  the  length  of  this  mesocolon  that  the  summit  of 
the  omega  loop  can  be  made  to  touch  the  caecum,  to  reach  the 
level  of  the  umbilicus,  or  even  to  touch  the  gall  bladder.  In 
some  examples,  I  have  found  this  loop  to  be  from  eighteen  to 
twentj'  inches  in  length.  If  the  long  tube  be  introduced  into 
such  a  coil,  its  extremity  may  reach  the  level  of  the  umbilicus 
and  yet  not  have  passed  beyond  the  sigmoid  flexure.  In  none 
of  the  many  experiments  I  made  upon  the  dead  body  could  I 
make  the  long  tube  pass  beyond  the  loop  of  the  sigmoid  flexure. 
In  one  case  that  I  saw  in  an  emaciated  subject  with  chronic 
obstruction,  the  surgeon  passed  a  long  tube,  and  demonstrated 
with  triumph  that  its  end  could  be  felt  near  the  umbilicus.  He 
maintained  that  the  instrument  had  reached  the  centre  of  the 
transverse  colon,  and  that  the  bowel  below  that  point  was  free. 
The  autopsy  that  came  to  pass  in  due  time  revealed  an  im- 
pervious stricture  of  the  commencement  of  the  sigmoid  flexure 
where  it  joined  the  descending  colon.  Apart  from  this,  this 
present  method  of  diagnosis  takes  no  account  of  abnormalities 
in  the  colon.  Even  if  it  be  presumed  that  the  sound  has 
forced  its  way  into  the  sigmoid  flexure,  it  may  then  have 
reached  one  of  those  very  extensive  and  tortuous  coils  that 
are  at  times  found  to  represent  this  segment  of  the  large 
intestine. 

Auscultation  of  the  Colon. — This  method  of  investi- 
gating the  intestine  was  considered  at  one  time  to  be  of 
value  in  diag^nosis. 


:m        DiAoyosTS  of  seat  of  OBSTRVcrioy. 

It  consists  in  auscultating  the  region  of  the  colon  and 
caecum  while  fluid  is  being  introduced  into  the  rectum  by 
means  of  an  enema  syringe.  It  was  stated  that  if  the  colon 
be  entirely  clear,  and  the  stethoscope  be  placed  over  the 
c£ecum,  the  water  can  be  heard  to  reach  that  part,  and  if  such 
be  the  case,  conclusive  evidence  is  afforded  that  the  obstruc- 
tion, wherever  it  may  be  placed,  is  at  least  not  in  the  large 
intestine. 

I  made  a  somewhat  extensive  inquiry  into  this  method  of 
diagnosis,  and  carried  out  experiments  upon  the  dead  body, 
and  made  numerous  investigations  in  cases  of  actual  obstruc- 
tion. At  first  I  was  disposed  to  think  the  measure  of  service 
in  determining  the  seat  of  the  obstruction,  but  further  experi- 
ence convinced  me  that  auscidtation  of  the  colon  in  cases  of 
intestinal  obstruction  was  absolutely  valueless  as  a  means  of 
diagnosis. 

Indican  in  the  Urine. — When  obstruction  concerns  the 
small  intestine,  then  there  is  a  very  marked  excretion  of 
indican  by  the  urine.  Indeed,  indicanuria  is  a  pronounced 
symptom  of  an  obstruction  so  placed.  Jaffe  says  that  in 
small-gut  obstruction  indican  in  considerable  amount  will  be 
found  in  the  urine  as  early  as  the  second  or  third  day. 
Nothnagel  states  that  if  no  indican  can  be  found  in  the  urine, 
the  obstruction  cannot  be  in  the  small  intestine,  the  case 
being  assumed  to  be  acute. 

Indicanuria  is  met  with  in  peritonitis,  and  it  also  occurs  in 
stenoses  of  the  colon  (especially  in  the  cancerous  forms)  when 
the  obstruction  has  lasted  for  a  long  time. 

The  value  of  indicanuria  as  a  diagnostic  symptom  has  not 
yet  been  fully  demonstrated.  It  is  said  to  be  met  with  in 
many  wasting  diseases,  and  ]3r.  Rose  Bradford  selects  cancer 
of  the  rectum  as  a  disease  affording  a  good  example  of  the 
symptom.  It  is  allowed  by  most  writers,  however,  that — as 
regards  obstruction — indicanuria  is  most  marked  when  the 
lesser  bowel  is  involved.     (See  also  page  809.) 

Indicanuria  is,  therefore,  of  no  diagnostic  value  if  acute 
peritonitis  be  present,  or  if  the  obstruction  have  been  of 
long  duration. 


8t!l 


CHAPTER    IV. 

THE    DIAC4X0SIS    OF    THE    DIFFERENT    FORiSrS    OF 
INTESTINAL    OBSTRUCTION. 

The  First  Step  in  the  Diagnosis. — Having  dealt  with 
certain  general  matters  in  connection  with  the  symptoms  of 
intestinal  obstruction,  it  now  becomes  necessary  to  deal  with 
the  particular  clinical  features  of  the  different  varieties  of  this 
trouble. 

Let  it  be  assumed  that  the  surgeon  has  brought  before  him 
a  case  of  intestinal  obstruction. 

He  can  have  no  difficulty  in  at  once  deciding  Avhether  the 
case  is  (A)  acute  or  (B)  chronic,  or  (C)  whether  it  is  a  chronic 
case  which  has  developed  acute  symptoms. 

An  outline  of  the  symptoms  of  these  three  types  of 
obstruction  has  already  been  given  on  page  285. 

After  this  elementary  point  has  been  disposed  of,  a  simple 
method  of  classification  Avill  soon  bring  the  case  into  its 
proper  category. 

A. — The  Case  is  Acute. — It  will  probably  belong  to  one 
of  the  four  varieties  enumerated  below: — 

1.  Strangulation  by  bands  or  through  apertures. 

2.  Yolvulus  of  the  sigmoid  flexure. 
8.     Acute  intussusception. 

4.     Acute  obstruction  by  gall  stones  or  foreign  bodies. 
For  internal  herni?e  see  page  102. 

The  morbid  anatomy  of  these  four  form.s  of  inte.stinal  obstruction 
is  dealt  with  on  pages  24,  126,  141,  and  185. 

Tlie  clinical  manifestations  of  certain  rare  and  anomalous  forms  of 
obstruction  due  to  bands  are  described  on  page  75. 

Owing  to  the  difficulty  of  classifying  internal  hernias  clinically,  the 
symptoms  of  all  forms  of  that  conditioQ  are  discussed  on  page  102. 

Volvulus  of  the  sigmoid  flexure  represents  the  only  common  form 
of  volvulus. 

The  rarer  forms  of  volvulus  are  described  on  page  133. 
V 


322  DIAGNOSIS. 

It  is  obviously  undesirable  to  complicate  the  clinical  classification 
of  intestinal  obstruction  by  the  introduction  under  separate  headings 
of  forms  which  are  quite  rare  and  often  merely  curious. 

Some  cases  of  intestinal  obstruction,  which  are  usually 
chronic,  may,  in  rare  instances,  follow  an  acute  course.  See, 
for  example,  the  cases  of  stricture  of  the  ileum  reported  on 
page  401. 

B. — The  Case  is  Chronic— The  trouble  may  be  due  to 
one  of  the  four  varieties  enumerated  below: — 

1.  Stenosis  of  the  small  intestine. 

2.  Stenosis  of  the  colon. 

3.  Chronic  intussusception. 

4.  Faecal  accumulation. 

The  morbid  anatomy  of  these  four  forms  is  dealt  with  on  pages 

141,  202  and  275. 

Under  the  term  stenosis  are  included  all  varieties  of  stricture,  and 
the  many  conditions  in  which  the  lumen  of  the  bowel  is  partly  occluded 
by  adhesions  (page  85),  by  matting  of  coils  together  (page  90),  by 
compression  from  without  (page  88),  by  bending  (page  98),  by  obstruct- 
ing substances  (page  194),  or  by  new  growths  (pages  259  and  269). 
See  also  some  forms  of  hernia  (page  102). 

C. — The  Case  has  been  Chronic  and  has  developed  Acute 
Symptoms. — The  cases  which  come  under  this  heading  are 
cases  of  chronic  obstruction  in  which  the  symptoms  of  that 
variety  are  present,  but  in  which  the  already  narrowed  bowel 
becomes  suddenly  occluded  and  acute  symptoms  are  pro- 
duced. This  variety  is  best  illustrated  by  a  stricture  of  the 
colon,  in  which  the  narrowed  part  of  the  gut  becomes  sudden- 
ly occluded  by  bending  or  kmking  of  the  bowel,  or  by  the 
blocking  of  its  lumen  by  a  foreign  body  which  has  been 
swallowed,  or  by  a  mass  of  undigested  food.  Similar  acute 
phenomena  may  supervene  in  any  case  of  chronic 
obstruction. 


323 


CHAPTER    V. 

ACUTE  INTESTINAL  OBSTRUCTION. 

General    Descriptiox   of  a   Case. — Onset. — The   onset   is 
sudden  and  abrupt. 

Pain. — The  patient  is  seized,  more  or  less  suddenly,  Avith 
acute  pain  in  the  abdomen.  This  pain  may  be  very  intense, 
may  cause  the  patient  to  be  "  doubled  up,"  or  even  to  roll  on 
the  floor.  It  is  relieved  by  pressure.  The  pain  is  like  that  of 
colic  somewhat.  It  is  often  described  as  a  "  tearing "  pain. 
It  is  continuous,  but  with  exacerbations.  It  does  not,  however, 
intermit  at  any  time,  nor  are  there  any  intervals  of  calm 
between  definite  paroxysms.  The  patient  often  feels  that  if 
he  could  pass  flatus,  or  a  motion,  the  pain  would  be  relieved. 

With  this  violent  pain  is  associated  more  or  less  collapse. 
This  may  be  profound,  and  may  imitate  the  collapse  of 
cholera.  The  patient  appears  to  be  suddenly  struck  down  by 
a  calamitous  disease.  In  almost  every  case  there  are  profound 
exhaustion  with  pallor  and  faintness,  and  an  expression  of 
intense  anxiety  and  distress. 

In  the  majority  of  cases  the  pain  is  referred  to  the  imme- 
diate vicinity  of  the  umbilicus.  In  only  a  few  instances  may 
it  be  relied  upon  to  correspond  to  the  seat  of  the  obstruction. 
The  pain  at  the  umbilicus  is  usually,  no  doubt,  a  referred 
pain,  the  site  being  the  mesenteric  plexus  (page  296).  The 
localisation  of  the  pain  is  often  very  misleading,  as  the  follow- 
ing examples  will  show : — The  pain  was  on  the  right  side,  just 
below  the  liver;  the  obstruction  was  in  the  ileum,  eighteen 
inches  from  the  crecum.^  The  pain  was  on  the  left  side,  and  on 
a  level  with  the  navel,  and  in  one  case  where  it  was  so  placed, 
a  coil  of  ileum  had  passed  through  a  rent  in  the  right  broad 
ligament,  t  while  in  another  the  strangulation    was   deep   in 

*  Med.  Timrs  and  Gazette,  vol.  ii.,  1876,  p.  651. 
t  Path.  Soc.  Trans.,  vol.  xii.,  \>.  lO.'i. 


324  ACUTE    INTESTINAL    OBSTIiUOTION. 

the  right  ihac  fossa. "^  The  pain  was  near  the  gall  bladder; 
the  obstruction  Avas  in  the  ileum.t  The  pain  was  in  the 
epigastrium,  and  the  trouble  that  caused  it  was  due  to  a  band 
passing  between  the  urinary  bladder  and  the  lumbar  spine.J 

It  may  be  said,  then,  that  the  position  of  the  pain  in  acute 
internal  strangulation  is  of  no  diagnostic  value  as  a  guide  to 
the  seat  of  the  lesion ;  that  it  is  more  often  complained  of 
about  the  umbilicus  than  elsewhere,  and  that  as  a  means 
of  ascertaining  the  locality  of  the  trouble  it  is  actually 
misleading. 

The  pain  that  is  so  conspicuous  a  feature  at  the  com- 
mencement of  these  cases,  persists  throughout  the  course 
of  them.  It  does  not,  however,  retain  its  original  intensity. 
It  soon  becomes  less  severe,  and  often  undergoes  considerable 
abatement.  In  some  of  the  more  acute  cases,  however,  it  has 
persisted  with  all  its  original  intensity,  until  deadened  by  the 
collapse  that  supervenes. 

The  pain  often  ceases  shortly  before  death.  This  circum- 
stance, however,  is  of  no  significance ;  it  is  usually  coincident 
with  a  profounder  collapse,  or  with  gangrene  of  the  bowel  in- 
volved, or  with  advanced  narcotism,  or  with  the  septicaemia 
with  which  these  cases  terminate. 

There  is  more  or  less  direct,  connection  between  the 
intensity  of  the  pain  and  the  sevei-ity  of  the  other  symptoms. 

One  or  two  cases  have  been  recorded  where  the  pain  has 
been  almost  an  insignificant  feature,  and  of  these  extremely 
rare  cases  no  satisfactory  explanation  can  be  given.  The 
most  striking  one  that  I  have  met  with  is  reported  by 
Mr.  Hulke.§  The  patient  was  a  man,  aged  thirty-two,  Avho, 
after  a  hearty  meal,  was  seized  with  sudden  abdominal  pain 
and  vomiting.  The  pain  soon  passed  off,  but  the  vomiting 
persisted  and  became  very  severe.  Neither  faeces  nor  flatus 
were  passed  by  the  rectum  On  the  tenth  day  the  vomiting 
Avas  fajculent,  but  the  patient  still  complained  of  little  or  no 

Eain.  Such  pain  as  there  was.  was  about  the  umbilicus, 
aparotomy  was  performed,  and  the  man  survived  the  opera- 
tion fifty- three  hours.  The  autopsy  revealed  a  coil  of  the 
lower  ileum  strangulated  beneath  a  band  formed  by  an 
epiploic  appendix  of  the  sigmoid  flexure,  which  had  become 
adherent  to  the  peritoneum,  near  the  right  sciatic  notch. 

Mr.  Marshy  reports  the  case  of  a  boy  who  was  attacked 

*  Unioij  Medicate,  1860,  p.  97. 

t  Brit.  Med.  Jovrn.,  vol.  i.,  1883,  p.  999. 

+  Bull,  de  la.  Soc.  Anat.,  1843. 

§  Medical  Times  and  Gazette,  vol.  ii.,  1877,  p.  482. 

II  Lancet,  vol.  i.,  1893,  p.  588. 


SYMPTOMS:    PAIN.  325 

wiih  sickness  after  eating  soine  unripe  fruit.  The  sickness 
abated,  but  on  the  sixth  day  it  returned  and  became  "  fVecal' 
There  was  but  Uttle  abdominal  distension,  and  no  action  of 
the  bowels.  Laparotomy  was  performed,  and  a  strangulation 
by  a  band  discovered  and  removed.  The  patient  recovered. 
Throughout  the  whole  period  of  the  case  the  boy  had  but 
very  trifling  pain. 

Among  fifty  well-recorded  cases  of  strangulation  by  a 
band,  I  found  eight  in  which  the  pain  was  described  as 
intermittent. 

The  circumstances  of  these  eight  examples  are  worthy 
of  brief  notice. 

1.  Female,  aged  fifty-three.  Pain  appear.s  to  have  been  only 
paroxysmal  at  the  commencement.  Case  of  strangulation  beneath  a 
band  :  laparotomy  with  cure  on  sixth  day. 

2.  Female,  aged  twenty-three.  Here  only  a  single  line  of  gut  \va.s 
found  beneath  a  band,  nut  a  knuckle  or  loop  ;  the  obliteration  of  the 
canal  was  therefore  a])parently  incomplete.  The  pain  is  merely  said  to 
have  "  persisted  on  and  oftVt 

3.  Feniale,  aged  twenty-six.  Case  of  strangulation  beneath  a  band. 
Here  the  strangulation  does  not  appear  to  have  been  severe  at  lirst,  and 
laparotomy  was  not  considered  necessary  until  the  eleventh  day.i 

-i.  Feniale.  aged  twenty-one.  Strangulation  beneath  a  band.  The 
incarceration  was  not  severe,  and  when  laparotomy  was  performed  on 
the  fourth  day  the  involved  coil  was  found  in  good  condition.  The 
patient  recovered.  § 

.5.  Male,  aged  forty-two.  In  this  case,  alluded  to  later,  there 
was.  besides  the  incai'ceration,  a  stricture  of  the  intestine,  to  which  the 
paroxysmal  pain  was  probably  to  no  small  degree  due.     {See  page  336.) 

6.  "  A  boy."     Case  of  strangulation  beneath  a  band. |! 

7.  Feniale,  aged  twenty-six.  Mr.  Bryant's  case  of  band  arising  from 
the  bladder.  Each  paroxysm  was  attended  with  strangury,  and  the 
"play"  allowed  to  the  band  by  its  mobile  point  of  attachment  probably 
prevented  the  obstruction  from  being  very  complete.     [See  page  337.) 

8.  Female,  aged  forty-five.  Paroxysms  every  half  -  hour.  Two 
bands  were  found  to  hold  down  two  portions  of  bowel.  Xeither  band 
compressed  the  gut  greatly,  and  the  upper  of  the  two  involved  coils  was 
but  very  slightly  pressed  upon  by  the  band.*^ 

In  the  majority  of  these  cases,  therefore,  there  is  some  reason  to 
suspect  that  the  obstruction  of  the  bowel  was  not  so  complete  as  it 
may  have  been,  nor  so  i)erfect  as  it  commonly  is. 

Vomiting. — Vomiting  is  a  conspicuous,  constant,  and  most 
distressing  symptom.  In  an  isolated  case  or  so,  it  has  been 
the   earliest    symptom   of    the    obstruction.      In    the  great 

*  Brit.  Med.  Juimi.,   1883,  p.  999. 
t  St.  Bart.'s  Hosp.  Reports,  vol.  xvii.,  p.  277. 
X  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,   1879.  p.  632. 
§   Ibid.,  p.  564. 

II  Sur  le  Diagnostic  et  Traitement  des  Etrangleinent  Internes.  These  de 
Paris,   1870. 

H  L'Dicet^  vol.  iL,  1873,  p.  773. 


326  ACUTE   JXTESTIXAL    OBSTRUCTION. 

majority  of  cases,  it  conies  on  immediately  after  the  appear- 
ance of  the  pain,  or  within  a  few  hours  after  that  event.  I 
have  met  with  instances  where  .the  vomiting  did  not  appear 
until  twenty-four  hours  after  the  onset  of  the  pain.^ 

As  regards  its  character,  the  ejected  material  consists,  first, 
of  the  contents  of  the  stomach,  and  then  usually  of  bilious 
matters,  being  of  a  dirty  green.  In  its  next  stage,  it  may  be 
thin  and  of  a  broA\Tiish  colour,  or  be  comparable  to  pea-soup, 
or  be  of  a  yellow  tint.  Vomited  matters  with  these  characters 
are  often  described  as  possessing  an  "  intestinal  odour." 
Lastly,  the  vomit  may  become  stercoraceous.f 

Stercoraceous  vomit  is  common  in  this  form  of  obstruction, 
and  occurs,  indeed,  in  between  50  and  60  per  cent,  of  the 
examples. 

The  period  in  the  attack  at  which  the  vomit  assumes  a 
stercoraceous  character  varies  from  the  second  to  the  ninth 
day.  An  average  taken  from  a  large  number  of  cases  gives 
the  fifth  day  as  the  mean.  The  cases  in  which  the  vomited 
matter  does  not  become  stercoraceous  are  represented  by  those 
in  which  death  occurs  at  an  early  period,  or  by  those  in  which 
the  progress  of  the  case  is  less  acute  than  usual. 

An  example  of  the  vomiting  of  blood  is  provided  by  Dr. 
J.  Cockle.  It  was  in  a  case  of  acute  strangulation  of  the  lower 
ileum  by  a  diverticulum.  The  patient  lived  only  two  and  a 
half  days.     The  vomited  matter  was  never  stercoraceous.  j 

Verj^  rarely  the  vomited  matter  contains  blood. 

When  once  it  has  set  in,  the  vomiting  will  persist  until  the 
termination  of  the  attack.  It  is  one  of  the  most  distressing  of 
the  symptoms.  Everything  swallowed  is  immediately  ejected, 
and  even  when  nothing  is  taken  by  the  mouth  the  vomiting 
Avill  continue  incessantl}^  Often  a  little  movement  or  a  little 
pressure  upon  the  abdomen  will  excite  an  attack.  When  not 
actually  sick,  the  patient  will  commonly  complain  of  a  most 
distressing  nausea,  and  will  be  troubled  by  eructations  ot 
flatus.  It  is  worthy  of  note  that  the  patient  is  in  no  way 
relieved  by  the  attacks  of  vomiting,  as  may  be  the  case  in  other 
maladies  associated  with  this  symptom.  The  amount  ejected 
at  a  time  varies.  It  may  be  very  copious,  especially  at  first. 
Later,  it  may  amount  to  a  mere  mouthful  each  time. 

With  few  exceptions,  the  longer  the  obstruction  lasts  the 
more  violent  and  distressing  do  the  attacks  of  vomiting 
become.     Sometimes  the}'  may  cease   entirely   a   few   hours 

*  See  cases  by  Dr.  Hilton  Fagge  ;  Guy's  Hosp.  Reports,  vol.  xiv. ;  and  Dr. 
Boeckel ;  Bull  et  Mem.  de  la  Soc.  de  Chir.,  tome  vi.,  1880,  p.  339. 

t  The  whole  subject  of  stei'coraceous  vomiting  is  considered  on  page  300. 
+  Brit.  Med.  Journ.,  vol.  ii.,  1882,  p.  785. 


SYMPT02fS :     VOMITING.  327 

before  death,  just  as  the  pain  may  abate  in  the  same 
circumstances.  In  other  cases,  however,  there  has  been  a 
sudden  and  profuse  gush  of  vomit  either  just  before  death  or 
in  the  act  ot  dying,  the  fluid  pouring,  Avithout  effort,  from  the 
mouth  and  through  the  nostrils.  This  is  also  sometimes 
observed  in  death  from  peritonitis. 

In  a  few  isolated  cases,  where  the  obstruction  does  not 
appear  to  have  been  very  complete  at  first,  the  vomiting  has 
undergone  distinct  abatement  after  the  violent  attack  marking 
the  onset  of  the  trouble  has  passed  away. 

Opium  has  often  a  very  decided  effect  upon  the  vomiting. 
When  the  patient  is  well  under  the  influence  of  the  drug,  the 
symptoms  of  intestinal  obstruction  may  be  more  or  less 
efficiently  masked.  The  pain  abates,  the  pulse  improves,  the 
amount  of  urine,  if  lessened,  increases,  and  the  vomiting 
becomes  less  troublesome  or  ceases  for  a  while.  Under  the 
influence  of  opium  stercoraceous  vomiting  even  may  cease,  and 
on  the  reappearance  of  the  symptom  the  ejected  matters  may 
be  non-fa?culent  for  a  while.  This  is  well  illustrated  by 
a  case  recorded  by  Mr.  Berkeley  Hill.  The  patient  was 
a  child  aged  ten,  and  the  obstruction  was  due  to 
strangulation  of  the  ileum  under  a  band.  By  the  third 
day  of  the  attack  the  vomiting  was  severe  and  fseculent. 
Opium  Avas  given.  For  four  hours  the  vomiting  ceased 
entirely,  and  when  it  returned  was  much  less  distressing,  was 
less  frequent,  and  was  non-stercoraceous.  Although  laparo- 
tomy was  not  performed  until  the  seventh  day,  "the  vomited 
matter  appears  never  to  have  again  become  feculent,  except 
on  one  occasion."^ 

In  this  and  like  cases  it  is  evident  that  the  drug  stills  the 
peristaltic  movement  of  the  intestine,  so  that  what  is  ejected 
is  merely  the  contents  of  the  stomach  and  of  the  highest  part 
of  the  smaller  bowel. 

Peritonitis,  presumably  by  the  paralysing  effect  it  has  upon 
the  intestine,  seems  to  have  some  influence  upon  the  produc- 
tion of  stercoraceous  vomiting.  AVhen  acute  peritonitis  sets  in 
early,  there  is  certainly  much  less  tendency  for  the  ejected 
matter  to  become  stercoraceous.  In  some  cases  this  has  been 
very  marked. 

In  nearly  every  instance  the  act  of  vomiting  is  associated 
with  much  retching  and  distress. 

Constipation. — Constipation  is,  as  a  rule,  absolute  from 
the  first,  and  continuous.  Neither  fjecal  matter  nor  flatus 
is  passed  after  the  onset  of  the  attack.  It  would  seem 
as   if  the  boAvel  below  the  seat   of  the   obstruction  became 

*  la i/cei,  vol.  i.,  1876,  p.  773. 


328  ACUTE    INTESTINAL    OBSTRUCTION. 

instantaneously  paralysed,  since  it  cannot  be  assumed  that 
in  every  case  the  colon  is  quite  empty  at  the  time  that 
the  strangulation  occurs.  A  special  exception  to  this  rule 
is  afforded  by  acute  intussusception,  in  which  there  is  a 
peculiar  type  of  diarrhoea. 

In  the  other  varieties  of  acute  obstruction  there  are  ver}' 
few  exceptions  to  the  condition  of  absolute  constipation. 

In  a  few  instances  a  motion  has  been  passed  during  or 
immediately  after  the  occurrence  of  the  initial  symptoms, 
having  been  derived  from  the  intestine  below  the  site  of 
the  strangulation.  Enemata  administered  almost  at  any 
time  after  the  commencement  of  the  attack  may  possibly 
bring  away  scybala  from  the  colon,  and  now  and  then  such 
scybala  come  away  repeatedly.  Flatus  generated  in  the 
large  intestine  may  also  be  passed,  but  the  circumstance 
is  quite  exceptional. 

I  have  met  with  a  few  recorded  instances,  in  cases  other 
than  intussusception,  where  blood  is  said  to  have  been  passed. 
In  one  case,  in  a  man  aged  fifty-three,  a  coil  of  the  lower 
ileum,  eighteen  inches  in  length,  was  strangulated  beneath 
a  band.  The  patient  died,  after  laparotomy,  on  the  sixth 
day.  Constipation  was  absolute  throughout,  but  the  patient 
is  said  to  have  passed  a  little  blood.  It  is  not  stated  if  the 
man  had  piles. ^  In  another  case  (the  case  by  Mr.  Berkeley 
Hill,  alluded  to  on  page  327)  enemata  on  two  occasions  brought 
away  scybala  and  blood.  The  patient  was  a  child  aged  ten, 
and  there  is  no  evidence  to  show  that  the  blood  was  derived 
from  the  seat  of  strangulation.  It  may  have  been  produced 
accidentally  by  the  enema  tube.  Nothnagelt  mentions  a 
case  in  which  some  80  cm.  of  the  lower  ileum  were  strangu- 
lated beneath  a  tight  band  connected  with  the  vermiform 
appendix.  The  patient  was  a  woman  of  tifty,  and  enemata 
are  stated  to  have  been  returned  stained  with  blood. 

At  autopsies  blood  is  frequently  found  in  the  engaged  coil 
and  in  the  intestine  above  it,  but  not,  so  far  as  I  am  aware, 
in  the  bowel  below  the  obstruction. 

The  passage  of  blood  from  the  bowel  is  a  conspicuous 
feature  in  acute  intussusception. 

A  more  or  less  copious  motion  may  be  passed  just  before 
death  or  in  the  act  of  dying.  In  most  of  the  examples  of 
this  occurrence  the  stool  is  derived  from  the  bowel  below 
the  obstruction,  subsequent  post-mortem  examination  having 
shown  that  the  occlusion  of  the  intestine  is  absolute.  In  a 
few  instances  the  unusual  motion  may  have  come  from  the 

*  T)v.  Fincham;  Med.  Timeji  mid  Gazette,  vol.  ii.,  1876,  p.  651. 
t  Die  Erkrankungen  des  Darmes,  Wien,  1896,  p.  337. 


CONSTITUTIONAL    SYMPTOMS.  329 

bowel  above  the  obstruction,  as  the  following  examples  will 
show : — 

In  one  case,  in  a  man  aged  twenty-one,  the  disease  had  assumed  a 
subacute  course,  the  patient  dying  on  the  thirteenth  day.  Constipation 
liad  been  absolute  throughout,  but  shortly  before  his  death  the  patient 
passed  a  copious  black  li(iuid  stool  into  the  bed.  The  autopsy  showed 
that  eight  inches  of  the  lower  ileum  had  become  strangulated  beneath 
a  band  passing  from  the  transverse  colon  to  the  cajcnm.  An  ulcer  ot 
the  stomach  was  found  to  have  perforated,  and  the  relief  thus  given  to 
the  distended  bowel  had  allowed  the  incarcerated  knuckle  to  become 
partly  withdrawn  from  under  the  band.  In  fact,  the  obstruction  at 
the  last  moment  had  ceased  to  be  complete.* 

In  another  case,  an  aperient  given  shortly  before  death  led  to  some 
greenish  loose  motions  being  passed.  The  obstruction  had  been  com- 
plete for  nine  days.  The  autopsy  showed  a  perforation  of  the  bowel 
above  a  coil  of  ileum  engaged  beneath  a  band.  The  mechanism  of  the 
relief  was  probably  the  same  in  this  case  as  in  the  preceding.f 

In  two  other  cases,  although  the  gut  w'as  in  each  instance  beneath 
a  band,  yet  the  main  cause  of  the  obstruction  was  a  volvulus  of  the 
engaged  coil.  Without  the  volvulus  the  obstruction  would  have  been 
but  partial.  It  will  be  shown,  in  speaking  of  twdst  of  the  small  intes- 
tine, that  the  constipation  in  such  cases  is  commonly  not  complete. 
In  one  of  the  examples  the  patient,  a  man  aged  twenty-one,  lived  forty- 
three  hours,  and  passed  two  liquid  motions  not  long  before  death. +  In 
the  other  case,  that  of  a  child  aged  four,  constipation  had  been  com- 
plete, and  all  the  symptoms  of  incarceration  were  marked  up  to  the 
fourth  day,  when  a  dose  of  croton  oil  produced  a  copious  evacuation. 
The  child  lived  until  the  tenth  day.§ 

Most  rarely  of  all  there  are  on  record  a  few  examples  of 
acute  intestinal  obstruction  (other  than  intussusception)  in 
which  there  has  been  some  diarrhoea. 

These  cases  have  been  for  the  most  part  attended  by  a 
cholera-hke  collapse.  The  condition  has  been  described  by 
Malgaigne  as  "  cholera  herniaire."  The  subject  is  considered 
under  the  heading  of  "  cholera  "  in  the  chapter  on  the  general 
diagnosis  of  intestinal  obstruction  (page  444). 

Constitutional  Symptoms. — An  initial  rigor  is  exceed- 
ingly rare.  In  one  example  ||  of  strangulation  the  patient 
had  several  rigors,  but  in  this  case  a  circumscribed  peritonitis 
was  developing  at  the  time  of  the  onset  of  the  olSstruction, 
and  was  probably  the  cause  of  the  shivering  attacks. 

Collapse  is  one  of  the  earliest  symptoms,  and  may  be 
profound  or  even  fatal.  Patients  attacked  with  acute  intes- 
tinal obstruction  have  been  found  lying  insensible  upon  the 

*  Dr.  Hihon  Fagge  ;   Guy's  Hospital  Keporls,  vol.  xiv.,  p.  27-. 
t  Bull,  de  la  Soc.  Anat.   de  Paris,   1861,  p.   118;  by  M.  Brichetau. 
X  M.  Le  Moyne ;    Contrib.    a    I'Etude  de  rOcclusion  Intestinale.       These 
de  Paris,  1878. 

§  Dr.  Kernot ;  Path.  Soc.  Trans.,  vol.  xv.,  p.  101. 

y  I\I.  Terrier;    Bull,  et  ilem.  de  la  >Soc.  de  C'hir.  de  Paris,  1870,  p.  o64. 


330  ACUTE    INTESTINAL    OBSTRUCTION. 

floor  of  their  bedrooms,  having  dropped  to  the  ground  as 
they  were  stepping  out  of  bed.  Among  the  histories  of 
acute  cases  are  instances  in  which  the  subject  of  severe 
obstruction  has  been  found  lying  in  a  water-closet,  cold, 
collapsed,  and  almost  senseless.  I  can  recall  a  case  in  which 
the  patient  was  seized  with  very  acute  strangulation  while 
in  his  study  late  at  night.  The  servants  had  retired,  and  he 
was  unable  to  summon  aid.  In  the  morning  he  was  found 
upon  the  floor,  cold  and  insensible,  with  evidences  of  copious 
vomiting.  He  seems  to  have  dropped  on  the  ground  on  his 
way  to  the  door.     The  case  was  rapidly  fatal. 

Collapse  of  an  extreme  degree  when  associated  with  some 
history  of  looseness  of  the  bowels  may  give  rise  to  a  suspicion 
of  cholera,  especially  if  cholera  is  prevalent  at  the  time. 
This  matter  is  alluded  to  in  the  chapter  on  the  general 
diagnosis  of  intestinal  obstruction  (page  444). 

There  is  great  muscular  weakness,  the  face  is  drawn  with 
pain,  and  has  an  aspect  of  horrible  anxiety,  the  features 
become  pinched,  the  eyes  sunken  and  surrounded  by  bluish 
rings,  and  the  voice  weak,  monotonous,  and  muflled.  A  cold 
sweat  breaks  out  upon  the  surface,  and  in  those  extreme  cases 
which  may  be  mistaken  for  cholera,  the  limbs  become 
cyanosed  and  the  complexion  livid.     The  lips  are  bluish-red, 

The  patient  is  the  subject  of  a  piteous  restlessness, 
turning  his  head  petulantly  from  side  to  side,  and  keeping 
his  hands  engaged  in  an  almost  constant  purposeless  move- 
ment. The  patient  usually  dies  with  those  manifestations 
of  general  septic  poisoning  which  mark  the  termination  of 
fatal  peritonitis.  The  intelligence  is,  as  a  rule,  retained  to 
the  last. 

The  pulse  is  small,  rapid,  soft,  and  thready,  and  varies 
with  the  general  condition.  It  is  usually  improved  up  to 
a  certain  point  by  opium. 

The  temperature  is,  as  a  rule,  subnormal  throughout.  The 
onset  of  peritonitis  will  commonly  not  affect  it,  but  now  and 
then  there  may  be  a  feeble  reaction,  and  the  temperature 
may  reach  to  99°  or  100''.  Such  examples  are  not  common. 
With  perforation  the  temperature  is  that  of  profound 
collapse. 

The  respirations  are  superficial  and  thoracic.  Should 
the  abdomen  become  much  distended  the  breathing  may 
be  embarrassed. 

The  tongue  is  usually  coated,  being  at  first  white,  then 
dry  and  brown. 

The  mouth  is  parched,  and  a  very  offensive  taste  is 
complained  of. 


CONSTITUTIONAL    SYMPTOMS.  331 

Intense  thirst  is  usually  a  prominent  and  distressing 
symptom.  It  is  most  marked  in  instances  associated  with 
profuse  vomiting,  and  in  those  attended  by  peritonitis. 

Obstinate  and  distressing  hiccough  is  occasionally  a  promi- 
nent feature.     It  is  rare. 

The  quantity  of  urine  is  very  commonly  diminished, 
and  in  the  most  acute  cases  may  be  entirely  suppressed,  the 
bladder  being  found  empty.  As  has  been  noted,  the  effect 
of  internal  strangulation  upon  the  renal  excretion  is  brought 
about  mainly  through  the  nervous  system  (see  page  808). 
A  diminution,  therefore,  in  the  amount  of  the  urine  is  most 
marked  in  the  most  acute  cases,  and  in  those  attended  by 
intense  pain  and  much  collapse.  In  many  instances  the 
excretion  of  the  urine  has  been  immediately  increased  on  the 
patient  coming  under  the  influence  of  opium.  The  position 
of  the  obstruction  in  the  small  intestine  has  no  effect  upon 
this  symptom.  It  may  be  absent  when  the  strangulation 
concerns  the  jejunum,  and  present  when  it  involves  the 
ileum. 

A  considerable  increase  in  the  amount  of  indican  excreted 
from  the  kidney  is  a  feature  of  acute  intestinal  obstruction 
when  it  involves  the  small  intestine.  {See  pages  308  and 
320). 

Strangury  is  very  rarely  noticed.  In  one  instance  in 
which  this  symptom  occurred  the  obstructing  band  was 
attached  to  the  bladder.  In  another  so  large  a  mass  of 
empty  coils  hung  down  into  the  pelvis  that  it  may  possibly 
have  pressed  upon  the  bladder.  The  patient  was  a  girl  aged 
ten,  and  the  mass  was  found,  during  life,  to  press  upon  the 
rectum. 

Tenesniiis  is  practically  unknown  in  the  acute  cases,  with 
the  notable  exception  of  intussusception.  In  intussusception 
tenesmus  is  a  prominent  symptom. 

In  some  6  per  cent,  of  the  cases  of  acute  strangulation 
crariips  are  complained  of.  The  subject  of  muscular  spasm  in 
connection  with  strangulation  of  the  bowel  has  been  fully 
investigated  by  M.  Berger."^  He  finds  that  the  cramping 
pains  are  usually  in  the  feet  and  calves,  that  the  symptom  is 
limited  to  cases  of  severe  strangulation,  and  is  most  common 
in  adults.  He  has  collected  fourteen  cases  where  this  feature 
was  noted.  Eleven  were  cases  of  strangulated  hernia,  two 
of  strangulation  by  a  band,  and  one  of  obstruction  by  a 
diverticle. 

It  is  in  a  case  of  this  kind,  associated  with  cramps  in  the 
limbs,  attended  by  profound  collapse,  with  a  cold  skin  and 

.    *  Bull,  ct  M6ra.  de  la  Soc.  de  Chir.  de  Paris,  vol.  ii.,  1867,  p.  698. 


332  ACUTE    INTESTINAL    OBSTRUCTION. 

cyanosed  extremities,  that  the  mistake  of  diagnosing  in- 
testinal obstruction  for  cholera  has  occurred.  This  error 
may  well  be  made  when  the  strangulation  has  been  preceded 
b}^  an  attack  of  diarrhoea. 

The  Condition  of  the  Abdomen. — The  abdominal  walls 
in  most  instances  remain  flaccid,  or  in  their  normal  condition 
until  such  time  as  local  or  general  peritonitis  sets  in,  or  dis- 
tension reaches  a  considerable  degree.  Even  in  some  cases 
where  peritonitis  was  found  after  death  the  parietes  have 
retained  their  normal  suppleness  to  the  end. 

In  certain  very  acute  cases  both  of  strangulation  by  bands 
and  of  intussusception,  the  abdominal  walls  have  been  found 
retracted  or  sunken  in  or  drawn  in  at  the  onset  of  the 
attack.  Most  of  the  examples  of  this  condition  have  been 
afforded  by  very  rigorous  strangidation  of  a  loop  of  small 
intestine. 

Meteorism. — Distension  of  the  abdomen  is  in  most  varieties 
of  this  form  of  obstruction  comparatively  slight.  It  usually 
appears  about  the  third  day.  It  seems  to  be  least  marked 
in  the  rapid  cases,  and  especially  in  cases  attended  by  extreme 
vomiting. 

In  acute  intussusception  meteorism  is  usually  absent, 
especially  in  the  early  stages  of  the  trouble. 

When  peritonitis  sets  in  the  meteorism  undergoes  a  con- 
siderable increase. 

The  swelling  is  usually  first  noticed  in  the  epigastric  and 
umbilical  regions,  and  may  form  a  very  distinct  elevation  of 
the  parietes  in  those  districts.  It  soon  becomes  more  or  less 
general,  and  the  abdomen  becomes  cask-shaped. 

A  special  exception  must  be  made  of  volvulus  of  the 
sigmoid  flexure,  in  which  meteorism  is  early,  is  pronoimced, 
and  is  often  at  first  definitely  localised. 

The  question  of  any  tumour  or  area  of  limited  dulness 
within  the  abdomen  is  discussed  under  the  separate  headings. 

Under  these  headings  is  also  considered  the  uncommon 
appearance  of  visible  coils  of  intestine  seen  through  the 
parietes. 

Local  tenderness,  as  demonstrated  by  pressure  upon  the 
abdomen,  is,  as  a  rule,  entirely  absent  at  first.  It  may 
never  appear,  especially  in  cases  pursuing  a  rapid  course. 
In  a  few  cases  of  a  less  acute  character  it  has  been 
trifling,  or  not  sufliciently  marked  to  attract  notice.  In 
the  majority  of  cases,  however,  some  part  of  the  abdomen 
becomes  tender  during  the  course  of  the  disease.  This 
tenderness  may  be  limited  in  extent,  or  diffused.  Limited 
tenderness  usuall}-  appears  about  the  second  or  third  day. 


STBANGTTLATION :    AGE.  ^33 

It  is  a  symptom  that,  when  well  marked,  is  of  some  diagnostic 
value,  since  it  appears  to  be  restricted  to  the  actual  seat  of 
the  lesion.  It  depends,  no  doubt,  upon  congestion  or  in- 
flammation of  the  involved  coils,  or  upon  some  peritonitis 
excited  in  their  serous  coat.  As  a  factor  in  diagnosis,  there- 
fore, it  is  of  more  value  than  is  the  spontaneous  pain  observed 
in  these  maladies. 

A  dift'used  tenderness  of  a  marked  nature  generally  in- 
dicates the  onset  of  a  peritonitis,  and  is  also  a  symptom  of 
clinical  value.  When  peritoneal  inflannnation  has  become 
diffused  a  general  tenderness  is  practically  constant,  unless 
modified  or  concealed  by  profound  collapse  or  narcotism. 

L  Strangulation  by  Bands  or  through  Apertures. — 
Tinder  this  heading  are  included  the  following : — 

Strangulation  by  isolated  peritoneal  adhesions. 
„  by  omental  cords. 

„  by  Meckel's  diverticulum. 

„  by  normal  structures  abnormally  attached,  as 

by  an  adherent  appendix  or  Fallopian  tube. 
„  through  slits  and  apertures  of  various  kinds. 

The  instances  of  obstructions  that  come  under  this  head- 
ing form  collectively  more  than  one-fourth  of  all  the  varieties 
of  intestinal  obstruction. 

Certain  anomalous  forms  of  obstruction  due  to  isolated 
bands  and  adhesions  are  dealt  with  on  page  75,  where  their 
clinical  features  are  also  considered. 

Internal  hernise  are  considered  on  page  102. 

The  clinical  phenomena  in  the  ordinary  cases  are  identical 
with  those  just  described  as  characteristic  of  acute  intestinal 
obstruction.  The  leading  features  are,  indeed,  those  of  an 
acutely  strangulated  hernia.  They  may  be  summarised  as 
follows : — 

History. — Age. — The  patients  are  mostly  young  adults. 

Strangulation  by  false  ligaments,  by  the  omentum,  by  the 
appendix,  and  through  abnormal  slits  and  apertures,  occurs 
most  frequently  in  persons  between  the  ages  of  twenty  and 
forty.  This  circumstance  obviously  depends  upon  the  fact 
that  the  forms  of  peritonitis,  with  which  these  affections  are  so 
intimately  associated,  are  most  common  between  these  ages. 
Perityphlitis  falls  with  greatest  frequency  between  the  ages  of 
ten  and  tliirt}^  Pelvic  peritonitis  occurs,  with  comparatively 
few  exceptions,  during  the  period  of  child-bearing,  and  as  a 
rule  early  in  that  period.  The  greatest  number  of  cases  of 
hernia  appear  for  the  first  time  during  the  twenty  years  in 
question.  During  the  same  period  also,  strangulation  of 
hernia  is  common,  and  perhaps  at  no  other  period  of  life  are 


334  STRANGULATION    BY   BANDS. 

injuries  of   a  severe  character  more  frequent,  or  abdominal 
operations  more  common. 

Many  cases,  however,  are  met  with  after  forty.*  Forms  of 
peritonitis  which  may  be  recovered  from,  and  which  lead  to 
adhesions,  may  occur  after  that  age,  and,  moreover,  strangula- 
tion of  the  bowel  may  not  occur  for  many  years  after  the 
peritonitis,  which  renders  it  possible,  has  passed  away. 

Before  twenty,  these  varieties  of  obstruction  are  com- 
paratively uncommon,  and  before  ten  they  are  very  rare.  In 
one  or  two  cases  of  incarceration  b}^  a  "  band "  in  young 
children,  the  strangulating  agent  was  probably  of  congenital 
origin  and  due  to  developmental  defects. 

Strangulation  by  means  of  the  true  diverticulum,  occurs 
most  frequently  during  the  twenty  years  between  ten  and 
thirty.  Of  the  two  decades  the  latter  presents  the  greater 
number  of  cases.  Leichtenstern  found  the  average  age  in 
seventy  cases  to  be  twenty-five  years.  He  notes  eight  cases 
between  the  ages  of  two  and  ten  years,  and  Trier  has  recorded 
a  case  in  an  infant  of  eight  months. t  Above  the  age  of  forty, 
strangulations  due  to  the  diverticulum  are  rare. 

Sex. — This  form  of  obstruction  is  a  little  more  common  in 
males  than  in  females.  While  pelvic  peritonitis  is  more  fre- 
quent in  females,  perityphlitis  is  a  little  more  common  in 
males.  It  is  curious  that  strangulation  by  Meckel's  diverti- 
culum is  more  often  met  with  in  male  subjects. 

Previous  History. — Out  of  fifty  fully  recorded  cases  there 
was  in  thirty -four  instances  (68  per  cent.)  a  history  of  such 
previous  trouble  as  may  have  produced  causes  for  obstruction. 
In  seventeen  cases  (84  per  cent.)  there  was  a  history  of 
peritonitis:  in  eleven  (22  per  cent.)  a  history  of  hernia;  in 
six  (12  per  cent.)  a  history  of  accident.  In  sixteen  cases 
(32  per  cent.)  there  was  nothing  in  the  previous  history  to 
note  under  this  heading.  These  sixteen  cases  included  several 
examples  of  the  diverticulum,  some  instances  of  slit  in  the 
mesentery,  and  a  few  patients  in  whom  adhesions  had  been 
found  without  any  circumstances  in  their  previous  history 
to  call  attention  to  the  occurrence. 

As  to  the  interval  of  time  that  may  have  elapsed  between 
the  causative  affection  and  the  actual  strangulation,  the 
greatest  variety  exists. 

Lucas-Championniere  X  records  five  cases  in  which  obstruc- 
tion symptoms  developed  a  few  days  after  operation.     One 

*  The  oldest  patient  of  whom  I  can  find  record  is  a  woman  aged  eighty,  who 
died  of  acute  obstruction  due  to  an  omental  band  after  hernia.  Lucas- 
Championniere  ;  Bull,  et  ^lem.  de  la  Soc.  dc  Chir.  de  Paris,  tome  v.,  1879,  p.  64i>, 

t  Pfaft's  Mittheil.  .lahrg.  iii.,  Heft  9. 

+  Kevne  de  Chirurgie,  1892,  p.  26-i 


sy^r^TO^rs.  335 

operation  Avas  for  the  removal  of  an  ovarian  tuiiionr  and 
four  were  operations  upon  hernia. 

Franklin''^  details  the  case  of  a  patient  who  developed 
csymptoms  of  aciite  intestinal  obstruction  four  days  after  he 
had  received  a  severe  blow  upon  the  abdomen.  The  obstruc- 
tion was  tound  to  be  due  to  a  band  of  recent  lymph. 

Harrison  Crippst  has  published  a  case  in  which  acute 
intestinal  obstruction  due  to  adhesions  set  in  eighteen  days 
after  the  removal  of  a  large  tumour  of  the  broad  ligament. 

In  several  reported  cases  weeks  or  months  have  elapsed 
between  the  obstruction  of  the  bowel  and  the  time  at  which 
the  cause  of  the  strangulation  was  probably  developed.  The 
longest  interval  of  this  kind  with  which  I  am  acquainted 
concerned  a  female  of  tifty-two  who  died  of  strangulation 
of  the  ileum  due  to  a  band  which  was  connected  with  the 
pelvic  peritoneum.  Twenty-one  years  before  her  death  she 
had  had  "  inflammation  of  the  womb  "  following  labour.  J 

With  regard  to  internal  strangulations,  due  directly  to 
hernia,  nearly  all  the  cases  have  been  in  connection  with 
ruptures  of  many  years'  standing.  In  one  patient,  aged 
eighty,  who  died  of  incarceration  of  the  bowel  by  an  omental 
band,  the  hernia  with  which  that  band  Avas  associated  had 
existed  for  sixty  years. 

Some  of  the  patients  among  the  above-mentioned  series 
of  fifty  cases  had  complained  of  previous  intestinal  troubles, 
such  as  severe  indigestion,  "  spasms,"  bilious  attacks,  and 
persistent  pains  in  the  abdomen.  The  number  of  individuals 
in  Avhom  such  symptoms  had  been  noticed  Avas  comparatively 
feAV,  and  it  is  questionable  Avhether  such  symptoms  were 
dependent  upon  the  cause  that  ultimately  brought  about 
the  obstruction. 

As  an  example  of  such  a  case  may  be  given  one  reported 
by  Dr.  J.  T.  Fox§  of  strangulation  beneath  a  Meckel's  diver- 
ticulum in  a  boy  aged  five,  Avho  had  had  previous  attacks 
of  "  stomach-ache." 

In  12  per  cent,  of  my  collected  cases  there  Avas  a  history 
of  previous  "  obstruction."  These  attacks  Avere  marked  by 
the  onset  of  a  sudden  and  severe  pain  of  a  colicky  character, 
associated  Avith  vomiting  and  constipation.  Their  duration 
Avas,  as  a  rule,  quite  short,  var^dng  from  one  to  three  days. 
Usually  there  had  been  only  one  such  attack  previous  to 
the   tinal   one.     In  rarer   instances   there  had  been    tAvo   or 

*  Zancef,  1893,  vol.  i.,  p.  273. 

t  £rit.  Med.  Journ.,  1894,  vol.  ii.,  p.  1103. 

X  Guy's  Hospital  Eeports,  vol.  xiv.,  p.  272. 

§  Path.  Soc.  Trans.,. 1898,  p.  103. 


336  STRANGULATION   BY    BANDS. 

tliree.  In  some  examples  these  previous  attacks  had  been 
very  severe.  There  is  little  doubt  but  that  in  not  a  few 
instances  the  repeated  attacks  of  obstruction  were  really 
outbreaks  of  relapsins;'  perityphlitis.  Mr.  Gay  has  given 
details  of  a  case  of  a  man  aged  forty-two  who  died  from 
strangulation  of  a  coil  of  ileum  beneath  an  adherent  appendix. 
During  the  four  years  that  preceded  his  death,  the  patient 
had  had  no  less  than  thirty  attacks  of  severe  pain,  associated 
with  vomiting  and  absolute  constipation.  This  case,  how- 
ever, Avas  complicated  by  a  stricture  of  the  small  intestine, 
to  the  occasional  plugging  of  Avhicli  these  thirty  attacks 
were  probably  due."^ 

Onset. — In  70  per  cent,  of  the  cases  the  onset  of  the 
attack  is  more  or  less  distinctly  sudden. 

In  the  instances  where  the  onset  has  been  gradual,  the 
patient  has  usually  had  some  slight  pain,  often  of  an  inter- 
mittent character,  with  trifling  vomiting,  and  a  constipation 
which  has  frequently  not  been  absolute.  Very  soon,  how- 
ever, the  symptoms  increase  in  severity  and  assume  all  the 
characters  of  those  of  acute  strangulation.  The  transition 
from  subacute  symptoms  to  acute  is  often  coincident  with 
the  administration  of  aperients. 

In  probably  about  two-thirds  of  the  cases  the  attack 
seems  to  have  come  on  when  the  patient  was  in  good  health, 
or  at  least  free  from  any  abdominal  disturbance.  Now  and 
then  it  has  set  in  suddenly  during  the  night  while  the  patient 
was  asleep.  In  about  one-third  of  the  cases  some  circum- 
stances have  immediately  preceded  the  symptoms  of  strangu- 
lation which  may  have  taken  an  active  part  in  producing 
the  obstruction.  The  fallacy,  however,  of  the  argument, 
"post  hoc  propter  hoc,"  may  enter  into  many  of  these 
relations,  or  the  supposed  exciting  cause  may  have  been 
really  a  part  of  the  symptoms  of  the  final  malady.  This 
would,  perhaps,  apply  to  those  instances  where  strangula- 
tion has  followed  upon  a  "bilious  attack"  or  upon  severe 
"  indigestion."  Putting  these  cases  aside,  however,  we  find 
that  the  obstruction  has  several  times  appeared  after  a  hearty 
meal,  and  especially  a  meal  of  indigestible  food.  In  con- 
nection with  hernia,  it  has  come  on  when  the  rupture  was 
down  or  giving  trouble.  In  two  instances  it  appeared  while 
straining  at  stool.  In  one  or  two  cases  it  has  come  on 
after  the  administration  of  a  purge.  In  a  case  reported  by 
Dr.  Hector  Mackenzie t  the  strangulation  symptoms  appeared 
after   the   patient  had  taken  one  drachm  and  a  half  of  oil 

*  Path.  Soc.  Trans.,  vol.  iii.,  p.  101. 
t  Ibid.,  1890,  p.  27. 


SYMPTOMS.  :ja7 

of  male  iern.  It  luis  followed  also  upon  a  sharp  attack  of 
diarrhoea.  In  quite  a  fair  number  of  patients  the  symptoms 
of  strangulation  have  made  their  appearance  either  during 
or  immeiliately  after  unusual  exertion.  In  one  instance  a 
peculiar  position  of  the  body  seems  to  have  had  some 
mtluence,  as  illustrated  by  a  case,  reported  by  Dr.  Quain, 
where  a  coil  of  ileum  was  found  strangulated  through  a 
slit  in  the  broad  ligament  of  the  uterus.  Here  the  attack 
came  on  suddenly  while  the  patient  was  bending  to  unlace 
her  boots.  In  a  remarkable  case  reported  by  Mr.  Bryant, 
a  distended  bladder  was  the  immediate  cause  of  a  strangu- 
lation being  produced.  In  this  instance  a  coil  of  bowel 
was  involved  beneath  a  band  which  passed  from  the  bladder 
to  the  lumbar  spine.  The  patient  had  been  out  for  a  drive, 
and  had  been  compelled  to  retain  her  urine  for  some  hours. 
Shortly  after  emptying  her  bladder  symptoms  of  acute 
obstruction  set  it.  Here  there  is  little  doubt  but  that  the 
distended  viscus  so  raised  the  band  out  of  the  pelvis  as  to 
allow  a  loop  of  gut  to  pass  beneath  it."^ 

Pain. — Pain  appears  early,  is  very  severe  and  persistent, 
and  is  mostly  located  about  the  umbilicus.  It  is  of  the 
nature  of  a  griping  pain,  and  is  continuous  with  exacerbations. 

Vomiting. — Vomiting  appears  early,  is  a  marked  symptom, 
being  constant,  copious,  and  severe.  In  60  per  cent,  of  the 
cases  it  becomes  stercoraceous,  on  an  average  on  the  fifth  day. 
It  afllbrds  the  patient  no  relief. 

Constipation. — Constipation  is  continuous  and  absolute 
from  the  first.  Enemata  may  evacuate  the  contents  of  the 
colon.     There  is  no  discharge  of  blood  from  the  rectum. 

Constitutional  Symptoms. — Collajjse  is  marked  and  the 
prostration  is  often  profound.  The  condition  of  the  pulse,  the 
temper atiire,  the  respirations,  and  the  tongue  has  already 
been  detailed  (page  829).  There  is  often  intense  thirst,  as 
already  mentioned,  and  notew^orthy  diminution  in  the  quantify 
of  urine  excreted  (page  331).     Tenesmus  is  absent. 

The  Condition  of  the  Abdomen. — The  abdominal  parietes 
are  flaccid,  unless  peritonitis  has  set  in. 

Meteorism  is  slight.  It  appears  usually  about  the  third 
day,  and  in  most  cases  involves  first  the  epigastric  and 
umbilical  regions. 

Local  tenderness  of  the  abdomen  is  absent,  at  least  at 
first. 

Tumours  or  localised  districts  of  dulness  caused  by  the 
distended  and  strangled  loops  are  extremely  rare,  and  are,  iu 
any  case,  very  indefinite. 

*  Med.  Times  and  Gazette,  vol.  i.,  1872,  p.  304. 


338  STRANGULATION   BY   BANDS. 

Coils  of  intestine  are  not  visible,  except  in  the  very  rarest 
of  instances. 

In  fact,  a  careful  examination  of  the  abdomen  b}'^  palpation 
in  these  cases  usually  reveals  nothing,  and  a  digital  examina- 
tion of  the  rectum  gives  equally  negative  results. 

There  are,  however,  some  few  exceptions  to  these  state- 
ments. (1)  Some  local  dulness  may  be  discovered  in  the 
otherwise  tympanitic  abdomen  ;  (2)  a  tumour  or  swelling  may 
be  detected  through  the  parietes ;  and  (3)  something  may  be 
revealed  by  an  examination  of  the  rectum. 

It  may  be  conceived  that  a  localised  area  of  dulness  on 
percussion  may  possiblj^  be  due  to  one  of  three  things :  to  an 
extravasation  into  the  peritoneal  cavity ;  to  large  coils  of  gut 
involved  in  the  strangulation  ;  or  to  the  empty  loops  of  bowel 
which  may  lie  below  the  point  of  obstruction.  With  regard 
to  a  definite  swelling  or  tumour,  it  will  be  reasonable  to  con- 
elude  that  it  could  depend  upon  the  second  only  of  these 
possible  causes.  It  must  be  no  matter  of  surprise  that  both 
these  phenomena  (the  dulness  on  percussion  and  the  swelling) 
are  very  rare.  Much  effusion  of  fluid  in  the  peritoneal  cavity 
is  very  uncommon  in  these  cases,  and  has  not  the  least 
tendency  to  become  localised  in  any  way.  Extravasations  ot 
blood  do  take  place,  but  never,  I  believe,  attain  such  magni- 
tude as  to  be  the  cause  of  dulness  on  percussion. 

In  the  second  place,  the  involved  bowel  is  often  a  mere 
knuckle,  and  is  very  commonly  found  against  the  posterior 
abdominal  wall  or  withm  the  pelvis.  In  any  case,  it  is  very 
apt  to  be  covered  over  b}'  the  distended  coils  above  the 
obstruction. 

In  the  third  place,  the  empt}^  coils  of  intestine  below  the 
site  of  the  incarceration  are  found,  with  comparativel}^  few 
exceptions,  to  hang  down  into  the  pelvic  cavity,  and  to  be 
thus  removed  from  examination. 

(1)  Localised  dulness  on  percussion,  and  (2)  a  tiinioiir  felt 
through  the  parietes. — Out  of  fifty  recorded  cases,  I  find  only 
six  examples  of  the  first  phenomenon  and  four  of  the  second. 
With  one  exception,  the  dulness  was  localised  in  the  right  iliac 
region,  the  rest  of  the  abdomen  being  tympanitic.  In  every 
instance  it  corresponded  to  the  site  of  some  little  tenderness 
on  pressure.  In  one  case,  it  was  due  to  the  matting  together 
cf  the  ileum  and  caecum  by  adhesions,  and  might  have  de- 
pended upon  still  existing  perityphlitis.  In  all  the  other 
examples,  it  was  caused  by  the  engorged  coil  involved  in  the 
strangulation.  This  coil  was  always  large,  varying  from  eight 
inches  in  one  case  to  two  metres  in  another.  In  the  exception 
above  alluded  to,  the  patch  of  dulness  Avas  just  to  the  right  of 


SYMI'TOMS.  XiS 

the  right  rectus  muscle.  Jt  was  caused  by  a  loop  of  strangu- 
lated jejunuui. 

The  tumour  detected  through  the  parietes  was  in  each 
case  caused  by  large  loops  oT  the  intestine  engorged  by 
strangulation.  In  one  example  the  incarcerated  coil  was 
tilled  with  blood.  Tn  three  cases  the  swelling  was  felt  in 
the  right  iliac  fossa.  In  the  fourth  case  it  was  in  the  middle 
line  and  extended  from  near  the  navel  almost  to  the 
pubes ;  it  was  not  observed  until  after  the  general  distension 
had  been  relieved  by  a  trochar,  and  was  caused  by  a  large 
coil  of  bowel  strangulated  by  a  diverticulum  adherent  to 
the  umbilicus.  The  swelling  seems  to  have  been,  in  each 
example,  ill-defined,  dull,  tender,  and  about  the  size  of  the 
fist.  It  is  remarkable  that  in  every  instance  the  mass  was 
not  felt  until  towards  the  end  of  the  case. 

(3)  A  tumour  felt  through  the  rectum. — Although  exten- 
sive coils  of  empty  and  flaccid  intestine  are  often  found 
hanging  inertly  into  the  pelvis,  it  is  seldom  that  they  have 
been  felt  during  life.  Such  cods,  when  they  are  capable  of 
being  appreciated  by  the  linger,  present  as  a  soft  doughy 
roundish  mass  which  can  be  felt  through  the  anterior  wall 
of  the  rectum. 

This  mass  has  been  the  subject  of  no  little  confusion,  and 
has  led  to  not  a  few  unsoimd  diagnoses. 

In  only  three  eases  out  of  the  fifty  just  alluded  to  were 
any  coils  of  intestine  visible  through  the  anterior  abdominal 
parietes.  One  was  a  case  of  acute  obstruction  associated 
with  a  remarkable  paroxysmal  pain  and  demanding  lapa- 
rotomy on  the  third  day.  The  other  cases  pursued  a  chronic 
course,  death  ensuing  on  the  thirteenth  and  fourteenth  days 
respectively.  The  movement  of  the  intestinal  coils  was 
visible  in  both  of  these  examples,  in  the  former  case  on 
the  tenth  day,  in  the  latter  on  the  seventh.  One  of  the 
patients  is  described  as  being  much  emaciated. 

These  cases  form  but  a  feeble  exception  to  the  rule  thiif 
visible  peristaltic  movements  are  met  with  only  in  case.s 
of  chronic  obstruction. 

2.  Volvulus  of  the  Sigmoid  Flexure. — This  is  the  only 
common  variety  of  volvulus.  Other  varieties  of  volvulus  are 
dealt  with  on  page  133.  Volvulus  of  the  sigmoid  flexure 
forms  about  one-fortieth  part  of  all  cases  of  intestinal  obstruc- 
tion. 

History. — Sex  ;  Age. — Volvulus  of  the  sigmoid  flexure  is 
more  common  in  males  than  females  in  the  proportion  of 
4  to  1.  It  is  very  rare  before  thirty.  The  patients'  ages  are 
usually  between  forty  and  sixty. 


340  VOLVULUS    OF   SIGMOID    FLEXURE. 

Previous  history. — In  nearly  every  case  there  is  a  history 
of  previous  constipation.  In  many  instances  the  constipation 
has  been  very  obstinate  for  years.  Some  of  the  patients 
have  been  the  subjects  of  occasional  attacks  of  diarrhoea. 
Some  particularly  indigestible  food  may  have  been  swallowed. 
There  is  often  a  history  of  colic,  which  is  relieved  by  placing 
the  body  in  a  certain  posture. 

Onset. — The  mode  of  onset  is  usually  sudden. 

Fain. — Pain  appears  early,  is  a  marked  symptom,  is  severe, 
but  not  usually  so  severe  as  in  the  previous  form,  and  is 
commonly  intermittent  at  first.  In  some  marked  cases  of 
paroxysmal  pain  the  patient  has  passed  a  motion  after  the 
commencement  of  the  attack.  The  pain  soon  becomes 
constant,  but  presents  exacerbations.  The  constant  pain  may 
be  due  to  the  volvulus  itself,  the  exacerbations  to  an  increase 
in  the  twist  from  peristaltic  action.  The  more  acute  the 
case  the  more  severe  the  pain.  It  is  at  first  complained 
of  about  the  umbilicus,  or,  less  frequently,  I  think,  about  the 
seat  of  the  sigmoid  flexure  itself.  As  the  case  advances, 
and  as  peritonitis  sets  in,  the  pain  becomes  more  diffused, 
beino-  often,  however,  most  felt  about  the  resfion  of  the 
distended  coil.  It  appears  to  diminish  rather  than  to  in- 
crease as  the  malady  advances.  There  are  cases  where  most 
pain  has  been  experienced  about  strange  parts,  such  as  the 
pubes  and  the  upper  and  left-hand  side  of  the  abdomen. 

Vomiting". — Vomiting  is  by  no  means  so  conspicuous  a 
symptom  as  it  is  in  strangulation  by  bands.  It  appears  less 
early,  and  may,  on  the  whole,  be  spoken  of  as  not  being 
very  severe.  It  may  be  absent.  There  has  been  quite  in- 
significant vomiting  in  patients  who  have  died  as  early  as 
forty-eight  hours  from  the  onset  of  the  attack,  on  the  one 
hand,  or  have  lived  for  a  week  or  ten  days  after  the  com- 
mencement. The  vomited  matters  are  at  first  alimentary, 
and  then  bilious.  Very  rarely  are  they  stercoraceous.  In- 
deed, stercoraceous  vomiting  occurs  in  only  15  per  cent,  of 
the  cases,  setting  in  (when  it  does  occur)  about  the  fourth 
or  fifth  day.  In  some  cases  the  vomiting  abates  consider- 
ably, or  is  even  absent  for  a  while.  As  already  stated,  it 
may  be  absent  at  first,  and  I  find  instances  where  the 
vomiting  did  not  commence  until  the  third,  fourth,  fifth, 
or  sixth  day  of  the  attack.  Liebaut  alludes  to  a  case  where 
vomiting  appeared  for  the  first  time  on  the  eighth  da3^ 

Frequent  eructations  are  singularly  common  in  this  form 
of  obstruction. 

Constipation — Constipation  exists,  as  a  rule,  from  the 
first,   and   is   absolute.      In   many   cases   scybala  have  been 


SYMPTOMS.  341 

removed  by  enemata,  but  they  have  evidently  been  derived 
from  the  rectum  below  the  volvulus.  In  a  few  instances 
a  motion  has  been  passed  during  the  progress  of  the  case, 
as,  lor  example,  on  the  second  or  third  day.  In  one  case 
scanty  motions  were  evacuated  during  the  first  three  days 
of  the  attack.  A  purge  has  produced  a  slight  stool  after  the 
symptoms  of  vomiting  have  set  in,  but,  as  a  rule,  aperients 
add  to  the  severity  of  the  manifestations  of  the  malady,  and 
to  the  completeness  of  the  constipation.  In  these  excep- 
tional cases  it  may  be  assumed  that  the  occlusion  of  the  two 
ends  of  the  loop  is  not  complete,  or  is,  at  least,  not  complete 
at  all  times.  The  scanty  stools  which  may  be  passed  are 
probably  derived  from  the  contents  of  the  flexure  itself,  and 
depend  upon  imperfect  closure  of  the  lower  end  of  the  loop, 
the  upper  end  being  still  entirely  occluded.  There  is,  as  a 
rule,  no  discharge  of  blood  from  the  rectum. 

Constitutional  Symptoms.— Co^/ap.se  is  not  so  marked 
as  in  the  previous  class  of  case.  Its  degree  depends  to  a 
great  extent  upon  the  suddenness  of  the  onset,  the  severity 
of  the  twist,  and  the  amount  of  bowel  involved.  In  the  most 
acute  cases  the  patient  dies  collapsed  within  forty-eight  hours. 

The  pulse  has  no  special  feature,  and  is  apt  soon  to 
assume  the  character  ol  the  pulse  in  peritonitis. 

The  te'tnjDerature  is  usually  below  normal  at  first,  and  may 
remain  so  until  death.  In  any  case  it  will  probably  be  found 
to  be  subnormal  until  peritonitis  sets  in.  Even  when  perito- 
nitis occurs,  no  appreciable  rise  in  temperature  may  be  noted, 
and  acute  peritonitis  has  been  found  in  the  autopsies  of 
patients  who,  throughout  the  whole  progress  of  the  attack, 
never  recorded  a  temperature  above  98-6.  As  a  rule,  how- 
ever, peritonitis  will  be  associated  with  an  increase  in  the 
bodily  heat,  an  increase  that  may  bring  it  up  to  the  normal 
level  or  a  little  above  it.  Thus  Dr.  Mayo*  quotes  a  case  in 
which  the  temperature  was  100  on  the  evening  of  the  third 
day.  The  thermometer  as  a  means  of  indicating  the  accession 
of  peritonitis  in  these  cases  is  of  little  value. 

The  respirations  are  usually  much  increased  in  frequency, 
a  symptom  which  depends  mainly  upon  the  great  and  often 
abrupt  distension  of  the  abdomen.  Dyspnoea  is  in  many  cases 
a  marked  feature,  and  a  great  sense  of  suffocation  and  of 
discomfort  about  the  thorax  has  been  complained  of 

As  will  be  pointed  out  below,  death  from  interference  with 
the  functions  of  the  thoracic  organs  is  not  infrequent  in 
volvulus  of  the  sigmoid  flexure. 

The  tongue  is   coated,   and    often    much    coated;    being 

*  Annals  of  Surgery,  1893,  p.   28. 


342  VOLVULUS    OF    SIGMOW    FLEXURE. 

at  first  moist,  and  then  usually  becoming  dry  and  Drown. 
Great  thirst  is  not  usually  complained  of  unless  there  has 
been  severe  and  copious  vomiting  or  much  collapse. 

In  the  acuter  cases  the  quantity  of  urine  is  as  a  rule 
diminished,  although  this  feature  is  not  so  marked  nor  of 
so  frequent  occurrence  as  it  is  in  the  cases  ot  strangulation 
by  bands.  As  occurs  in  that  form  of  obstruction,  so  in  this; 
the  more  marked  the  pain  and  collapse  and  evidences  of 
general  constitutional  disturbance,  the  more  likely  is  the 
quantity  of  urine  to  be  diminished,  while  under  the  influence 
of  opium  the  diminished  excretion  may  again  attain  to  its 
normal  proportions. 

The  question  of  the  increase  of  indican  in  the  urine  is 
alluded  to  on  pages  308  and  320. 

In  only  one  case  within  my  knowledge  does  strangury 
appear  to  have  been  a  symptom.  In  this  isolated  instance 
the  patient  was  seized  on  the  second  day  of  the  attack 
with  such  a  very  frequent  desire  to  urinate,  that  he  was 
thought  to  have  cystitis.  He  died  sixty-tour  hours  after 
the  appearance  of  the  first  symptom.  The  distended  sig- 
moid flexure  was  found  to  have  reached  the  diaphragm. 
He  never  vomited  except  to  reject  some  oil  he  took.  If 
vomiting  is  in  these  cases,  to  a  great  extent,  the  result  of 
reflex  nerve  disturbance,  it  would  appear  as  if  in  this  instance 
the  nerve  apparatus  of  the  bladder  had  been  irritated  instead 
of  that  of  the  stomach.  The  man  might  almost  be  said  to 
have  vomited  with  his  bladder  instead  of  with  his  stomach. 

Tenesmus,  as  may  be  expected,  is  often  noticed  in  volvulus 
of  the  sigmoid  flexure.  It  may  be  expected  to  occiu*  in 
some  15  per  cent,  of  the  cases. 

The  Condition  of  the  Abdomen. — The  abdominal  walls 
soon  become  rigid,  partly  on  account  of  the  degree  of  dis- 
tension and  partly  on  account  ot  the  early  and  almost  con- 
stant appearance  of  at  least  local  peritonitis. 

Meteorism. — One  of  the  most  conspicuous  features  in  vol- 
vulus of  the  sigmoid  flexure  is  the  enormous  distension  of  the 
abdomen.  This  distension  appears  very  early  and  attains  very 
considerable  proportions.  It  depends  mainly  upon  the  dilata- 
tion of  the  sigmoid  flexure  itself,  although  there  is  much  dis- 
tension of  the  rest  of  the  intestine.  The  rapidity  Avith  which 
the  meteorism  develops  is  remarkable.  In  patients  who 
have  died  in  sixty-four  or  sixty-eight  hours,  the  twisted 
bowel  has  been  found  to  reach  the  diaphragm,  and  has 
appeared  at  first  sight  to  occupy  the  whole  of  the  abdomen. 
The  swelling  is  usually  localised  at  first,  appearing  as  a 
rounded  elevation  in  the  left  segment  of  the  umbilical  region, 


SYMPTOMS.  343 

and  then  occupying  the  whole  of  that  region,  together  with 
the  epigastrium.  In  the  matter  of  locality,  however,  it  shows 
much  variety.*  Very  soon  the  swelling  becomes  uniform  and 
the  abdomen  appears  as  evenly  blown  out  asadistended  bladder. 

The  swelling  which  forms  early  in  the  case,  may  be  dull 
over  some  part  of  its  extent  and  of  well  limited  outline. 
Such  was  the  case  in  a  patient  whose  history  is  recorded  by 
Mr.  Spencer  Watson.  Here  a  dull  rounded  swelhng  was 
detected,  which  the  autopsy  showed  depended  upon  a  vol- 
vulus of  globular  outline  and  about  the  size  of  a  child's 
head.t  Much  thickening  of  the  wall  of  the  volvulus 
from  infiltration,  would  obviously  tend  to  diminish  its 
resonance  on  percussion.  Since  the  volvulus  always  ex- 
tends in  front  of  the  other  intestines,  all  its  parts  must  be 
more  or  less  exposed  to  examination  through  the  parietes. 

Tenderness  on  pressu7'e  is  absent  at  first,  although  when 
the  early  pain  is  felt  about  the  region  of  the  volvulus, 
pressure  there  may  add  to  its  intensity.  As  peritonitis  com- 
mencing in  the  distorted  loop  is  very  constant,  it  happens 
that  tenderness  soon  develops  over  the  region  the  gut 
occupies,  and  as  the  peritonitis  becomes  general,  so  also  does 
the  tenderness  become  diffused.  There  is  no  iorm  ot 
intestinal  obstruction  where  marked  pain  on  pressure  is 
elicited  earlier  than  in  the  present  cases,  if  exception  be  made 
of  certain  examples  of  acute  intussusception. 

In  a  few  cases  the  movements  of  coils  of  intestine  have 
been  visible  through  the  parietes  before  the  distension  had 
reached  a  great  magnitude.  This  visible  peristalsis  cannot  be 
regarded  as  associated  with  the  volvulus,  but  rather  as  due  to 
a  long-continued  obstruction  in  the  bowels,  upon  which  the 
twist  itself  had  probably  depended.  Out  of  a  series  of 
twenty  well-recorded  cases,  I  have  met  with  only  two 
instances  of  this.  In  both  the  attack  came  on  gradually, 
and  in  both  there  was  a  history  of  long-continued  previous 
constipation.  One  of  the  patients  lived  seven  days,  the 
other  eight. 

Other  Forms  of  Volvulus. — It  will  be  convenient  to 
describe  here  the  clinical  manifestations  which  attend  other 
and  rare  forms  of  volvulus.  These  varieties  of  volvulus  are 
fully  described  on  page  132,  and  the  symptoms  of  each  form 
will  be  considered  in  the  order  in  which  the  varieties  are 
placed  in  the  section  on  pathological  anatomy. 

*  In  one  case  at  least  the  swelling  was  most  conspicuous  in  the  right  iliac 
region.  The  twisted  gut  usually  passes  towards  that  fossa  before  it  mounts  up 
in  the  abilumen. 

f  Med.  Times  and  Gazette,  vol.  ii.,  1879,  p.  31. 


U4,  VOLVULUS    OF    COLON. 

(1)  A  Form  of  Volvulus  in  which  the  Sigmoid  Flexure 
IS  Intertwined  with  a  Coil  of  Small  Intestine. 

A  description  of  this  form  of  twist  is  given  on  page  132. 
Leichtenstern  has  collected  twenty-one  examples  of  this 
curious  lesion.  With  one  exception,  all  the  patients  were 
males,  the  ages  ranging  between  twenty-four  and  seventy- 
three. 

In  all  the  strangulation  was  of  a  very  severe  type. 

The  symptoms  attending  these  cases  are  those  of  strangu- 
lation of  a  very  acute  character.  The  onset  is  more  or  less 
sudden,  a  marked  degree  of  collapse  is  soon  developed, 
vomiting  is  incessant  and  profuse,  there  is  great  pain  and 
absolute  constipation.  The  symptoms,  indeed,  are  those 
incident  to  acute  strangulation  of  the  small  intestine.  Diar- 
rhoea is  apt  to  precede  this  kind  of  incarceration  of  the 
bowel,  and  a  loose  stool  may  be  passed  after  the  onset  ot 
the  symptoms.  It  is  evident  that  the  great  engorgement  of 
the  involved  coils  in  these  cases  would  lead  to  a  copious 
discharge  of  fluid  into  the  cavity  of  the  intestine.  Meteorism 
is  usually  prominent.  In  the  matter  of  diagnosis  it  would  be 
practically  impossible  to  distinguish  these  cases  from  cases  of 
strangulation  of  a  large  loop  of  intestine  by  a  "  band,"  or 
through  an  aperture. 

Death  is  very  rapid.  In  only  one  case  out  of  the  twenty- 
one  just  alluded  to  did  the  patient  live  until  the  sixth  day. 
All  the  rest  died  within  the  flrst  two  days,  and  many  within 
the  first  twenty-four  hours. 

It  will  be  seen  from  this  that  the  present  form  of  ob- 
struction constitutes  one  of  the  most  acute  forms  of  strangu- 
lation of  the  bowel  that  is  known. 

(2)  Volvulus  of  the  Ascending  Colon  and  C^cum. — A 
description  of  this  form  of  volvulus  is  given  on  page  133. 
There  are  three  varieties  of  this  condition. 

(A)  The  ascending  colon  is  twisted  around  its  own  axis. 

(B)  There  is  a  volvulus  of  an  abnormal  loop  formed  by  an 
ascending  colon  and  ejecum  provided  with  a  long  and 
distinct  niesocokm. 

(C)  The  ctecnni  is  twisted  ai-ouud  its  own  axis,  or  "bent 
upun  itself." 

(A)  Of  the  first  of  these  three  varieties  I  have  been  able 
to  find  but  one  example.     It  is  described  on  page  133. 

(B)  The  symptoms  in  these  cases  are  not  so  acute  as  in 
corresponding  examples  of  volvulus  implicating  the  sigmoid 
flexure.  In  Mr.  Firth's  case,  for  example  (see  page  134),  the 
attack  began  with  sudden  pain,  followed  by  vomiting,  which. 


SYMPTOMS.  34."> 

however,  did  not  become  severe  until  the  next  day.  The 
abdomen  became  distended  and  tender,  and  the  bowels 
absokitely  confined.  On  the  fifth  day  laparotomy  was  per- 
formed, but  the  obstruction  was  not  found.  "  Fseculent " 
vomiting'  commenced.  On  the  evening  of  the  sixth  day  the 
vomiting  abated  and  ceased  to  be  stercoraceous.  On  the 
seventh  day  the  bowels  were  opened  eight  times.  The 
patient  became  gradually  worse,  and  died  collapsed  on  the 
eighth  day.  Perforation  of  the  crecum  had  occurred.  There 
was  commencing  general  peritonitis. 

(C)  The  symptoms  of  volvulus  of  the  caecum  vary  greatly, 
and  even  among  the  five  instances  alluded  to  on  page  13o  there 
are  examples  of  an  acute,  of  a  subacute,  and  of  a  chronic 
case.  Four  of  the  patients  were  males,  one  a  iemale.  Their 
ages  ran  between  twenty-eight  and  fifty-five.  The  fatal 
attack  had  in  one  case  been  preceded  by  severe  diarrhoea,  and 
in  the  other  instances  by  obstinate  constipation.  In  two 
examples  the  onset  may  be  said  to  have  been  sudden,  while 
in  the  remaining  cases  it  was  gradual.  Dr.  Jones's  patient 
was  seized  suddenly,  soon  after  a  meal,  with  pain,  followed  by 
vomiting  and  constipation.  On  the  third  day  of  the  ob- 
struction, as  the  patient  was  getting  out  of  bed  he  became 
suddenly  collapsed  and  died  in  a  few  minutes  of  syncope. 
In  one  of  Dr.  Fagge's  cases  the  attack  ended  fatally  in  three 
and  a  half  days.  In  another  case  the  attack  was  subacute 
There  was  pain  which  subsided  once  and  then  returned ; 
constipation  which  yielded  once  and  then  persisted  ;  vomiting 
which  became  stercoraceous  on  the  twelfth  day  and  "  faecal " 
shortly  before  the  patient's  death  about  the  eleventh  day. 
In  another  instance  the  patient  died  four  months  after  ad- 
mission into  hospital,  the  chief  symptom  during  that  time 
being  obstinate  vomiting.  In  one  other  patient  there  had 
been  severe  constipation  for  two  weeks,  but  vomiting  did  not 
set  in  until  the  day  before  death. 

The  symptoms,  therefore,  show  every  variation  between 
acute  obstruction  of  the  colon  on  the  one  hand  and  chronic 
or  partial  obstruction  on  the  other. 

Distension  of  the  abdomen,  often  of  an  irregular  character, 
was  constant.  In  all  cases  peritonitis  was  found  at  the 
autopsy.  The  caecum  was,  in  every  example,  of  enormous 
proportions.  It  one  case,  it  is  said  to  have  filled  nearly  one 
half  of  the  abdomen,  and  in  another  instance  to  have  appa- 
rently occupied  the  greater  part  of  that  cavity.  Once  it  is 
spoken  of  as  gangrenous,  and  in  two  instances  it  was  either 
ruptured  or  perforated. 

(8)  Volvulus  of  the  Small  Ixtestine. — On  reference  to 


346  VOLVULUS    OF   SMALL    INTESTLNE. 

the  description  of  these  lesions  given  on  page  135,  it  will  be 
seen  that  the  volvulus  may  assume  one  of  two  forms. 

(A)  There  is  a  Volvulus  of  the  Small  Intestine  about  its 
Mesenteric  Axis. 

The  reader  is  referred  to  the  account  already  given  of  this 
form  of  volvulus  (page  135). 

The  symptoms  met  with  in  this  volvulus  vary  consider- 
ably. The  course  of  the  malady  may  be  acute  or  chronic. 
One  patient  out  of  those  alluded  to  on  page  135  exhibited 
symptoms  of  partial  obstruction  for  thirty-six  days,  while 
another  was  troubled  with  abrupt  attacks  of  obstruction  at 
uncertain  intervals,  for  more  than  a  year  before  death 
occurred.  In  the  remaining  cases,  the  average  duration  of 
the  attack  was  five  days,  the  extremes  being  thirty-two 
hours  and  nine  days. 

In  most  of  the  cases  the  attack  came  on  suddenly.  In 
several  instances  no  cause  could  be  assigned  for  the  intestinal 
trouble.  In  other  cases  diarrhoea,  or,  less  frequently,  constipa- 
tion, had  preceded  the  symptoms  of  obstruction.  Pain 
appears  to  be  always  the  first  symptom  complained  of.  It  is 
severe  and  of  a  colicky  character,  and  at  first  usually  localised 
about  the  umbilicus.  As  the  case  progresses,  and  probabl}^  as 
some  local  peritonitis  sets  in,  the  pain  may  become  more 
definitely  localised.  In  several  examples  it  is  described  as 
continuous  but  with  exacerbations.  There  is  usually  no  ten- 
derness at  first,  although  that  symptom  may  appear  before  the 
termination  of  the  case.  It  depends  probably  upon  the 
development  of  some  peritonitis. 

Vomiting  appears  early.  It  is  a  marked  symptom,  but 
would  seem  to  occur  rather  at  long  intervals  and  in  large 
quantities  than  to  be  incessant  and  less  copious.  Out  of  eight 
recorded  cases,  the  vomited  matter  became  stercoraceous  in 
two  instances ;  in  five  instances  it  is  described  as  non-stercor- 
aceous,  and  in  the  remaining  case  all  description  is  lacking. 
In  one  of  the  cases  where  the  vomiting  was  non-stercoraceous, 
the  duodenum  was  involved,  and  in  another  the  jejunum. 

Constipation  is  usually  complete  from  the  first.  The  lower 
bowel  may,  however,  be  emptied  by  enemata  of  any  contained 
fseces,  and  occasionally  a  motion  has  been  passed  that  may 
have  been  due  to  some  temporary  relaxation  of  the  volvulus. 
Naunym  reports  a  case  of  volvulus  of  the  lesser  bowel  in 
which  much  blood  was  passed  per  anum. 

The  abdomen  soon  becomes  swollen,  and  an  indistinct 
mass  or  tumour  may  be  felt  within  if  the  twisted  bowel  be 
of  good  length  and  in  a  position  to  present  itself  beneath  the 
parietes.     In  one  case,  where  the  lower  ileum  was  implicated, 


SYMPTOMS.  847 

the  patient  complained  of  seA^ere  tenesmus  and  of  a  sensation 
as  of  a  cord  encircling  the  body. 

Mr.  Harrison  Cripps  has  recorded  a  case  of  congenital 
volvulus  of  the  ileum  which  is  probably  unique.  The  child 
had  had  no  action  of  the  bowels,  suffered  from  obstinate  con- 
stipation and  frequent  vomiting.  Littre's  operation  was  per- 
formed on  the  third  day  of  life  under  the  impression  that  the 
rectum  was  malformed.  The  infant  died  of  peritonitis.  The 
colon  was  found  to  be  normal,  and  the  volvulus  to  be  slight 
and  very  readily  reduced. 

In  one  of  the  chronic  cases  (in  a  girl  aged  ten)  the  attack 
came  on  suddenly  with  intense  pain,  vomiting,  and  tenesmus. 
The  acute  symptoms  soon  subsided,  and  the  case  became 
chronic.  The  somewhat  obstinate  constipation  was  interrupted 
by  an  occasional  stool,  the  vomiting  became  stercoraceous,  the 
abdomen  was  much  distended,  and  showed  through  its  parietes 
the  peristaltic  movements  of  the  bowels.  The  child  was  much 
emaciated,  and  died  at  the  end  of  thirty-six  days,  after 
twenty-fours  of  intense  abdominal  pain.  There  was  a  volvulus 
of  the  lower  ileum,  but  no  peritonitis.^  In  another  chronic 
case,  the  patient  had  no  less  than  seven  severe  attacks  of 
obstruction  in  a  little  more  than  twelve  months.  These 
attacks  were  somewhat  sudden  in  their  onset  and  associated  with 
constipation,  vomiting,  and  severe  pain.  They  were  reUeved, 
as  a  rule,  at  the  end  of  a  few  days  by  means  of  enemata,  the 
patient  recovering  often  very  slowly.  Here  the  volvulus  was 
in  the  upper  end  of  the  jejunum.  This  case  suggests  the 
possibility  of  spontaneous  cure  in  cases  of  volvulus. 

In  the  more  acute  cases  some  peritonitis  is  common. 

Nothnagelt  describes  a  case  in  a  man  aged  thirty.  He  was 
seized  with  violent  pain  about  the  navel  which  lasted  some 
ten  minutes.  He  then  vomited  and  passed  a  soft  stool.  No 
more  vomiting  occurred,  but  each  day  he  was  seized  with 
violent  attacks  of  colic,  the  pain  being  about  the  umbilicus. 
Each  day  a  slight  motion  was  passed  with  or  without  an 
enema.  On  the  fourteenth  and  fifteenth  days  of  the  disease 
he  again  vomited.  Much  tympanitic  distension  of  the 
abdomen  ensued.  He  gradually  sank,  and  died  on  the  nine- 
teenth day.  The  autopsy  revealed  a  volvulus  of  the  upper 
jejunum,  the  mesentery  of  which  was  twisted  more  than  once 
round.     There  was  general  peritonitis. 

Leichtenstern  describes  a  volvulus  that  implicated  the 
whole  of  the  jejuno-ileum.  As  I  have  been  able  to  find  no 
other  cases  than  the  few  to  which  he  alludes,  I  might  give 

*  Dr.  Handfield  Jones;  Med.  Times  and,  Gazette,  vol,  i.,  1872,  p.  3. 
f  Die  Erkraiikungen  des  Darmcs,  VVien.,  1896. 


3!8  ACUTE    INTUSSUSGEPTIOX. 

the  account  of  this  form  of  twist  in  his  own  words :  "  If  the 
root  of  the  ni(smtery  be  unusually  short,  while  its  height  and 
the  length  of  the  intestine  are  normal,  if  the  radix  mesenterii 
runs  more  vertically  than  usual,  if  the  mesentery  attains  its 
full  height  at  the  jejunum  suddenly,  and  loses  it  just  as 
abruptly  in  the  neighbourhood  of  the  caecum,  then  the  small 
intestine  is  in  a  condition  to  undergo  twisting  as  a  whole 
about  its  mesentery.  The  twist  is  usually  180  degrees,  and 
the  direction  such  that  the  upper  end  of  the  intestine  is 
carried  to  the  left  and  downwards,  the  lower  end  to  the 
right  and  upwards.  The  right  side  of  the  mesentery  faces  to 
the  left,  and  the  left  to  the  right.  This  twist  does  not  always 
cause  absolute  occlusion,  often  only  a  constriction  at  each 
end  of  the  twisted  convolution,  the  beginning  of  the  jeju- 
num and  the  end  of  the  ileum,  the  latter  of  which,  when 
occlusion  takes  place,  is  often  twisted  at  the  same  time  about 
its  own  longitudinal  axis.  Twisting  of  this  kind  has  been 
seen  in  very  young  children,  and  it  seems  as  if  that  variation 
in  the  development  of  the  mesentery  in  which  the  ileum, 
caecum,  and  ascending  colon  possess  a  common  mesentery, 
especially  disposed  to  it."^ 

Dr.  Whipham  reports  a  case  where  "  the  small  gut  with 
the  caecum  and  ascending  colon  were  attached  by  their 
mesenteric  envelopes  to  the  same  point  near  the  last 
dorsal  vertebra;  so  that  the  usual  attachment  of  the  colon 
to  the  right  iliac  fossa  was  deficient.  The  pedicle  of  con- 
joined mesentery  was  twisted  from  left  to  right  across 
and  around  the  union  of  the  duodenum  with  the  jejunum, 
so  as  to  compress  that  part  firmly."  The  jejunum  was 
in  the  early  stage  of  gangrene.  The  patient,  a  female, 
aged  nineteen,  had  presented  symptoms  of  intestinal 
obstruction  for  twelve  days  before  her  death.  She  suffered 
from  severe  vomiting  which  was  never  stercoraceous,  and 
from  constipation  which  was  relieved  once  during  the  twelve 
days.  There  was  no  swelling  of  the  abdomen  save  a  little 
in  the  epigastric  and  hypogastric  regions.  She  had  had 
previous  attacks  of  constipation  attended  with  colic  and 
sickness,  t 

(B)  Two  Suitable  Coils  of  Small  Intestine  are  Tiuisfed 
Together. — In  this  very  rare  form  one  coil  of  gut  acts  as 
an  axis  around  whif'h  the  other  is  wound.  All  that  is 
known  clinically  of  tl  is  curious  accident  is  given  on  page  140. 

3.  Acute  Intussusception. — Intussusceptions  form  about 

*  Log.  cit.,  p.  565. 

f  Med.  Times  and  Gazette,  1876,  vol.  ii.,  p.  33. 


SYMPTOMS.  3^9 

30  per  cent,  or  a  little  less  than  one-third,  of  all  species  of 
obstructions  of  the  bowels. 

As  regards  the  clinical  phase  of  the  invaginations,  it  may 
be  estimated  that  some  So  per  cent,  are  acute  or  subacute 
and  some  15  per  cent,  are  chronic. 

History. — Sex. — Intussusception  is  more  common  in 
males  than  in  females.  Of  Leichtenstern's  442  cases,  285 
occurred  in  males  and  157  in  females.  Mr.  Gay,  however, 
dealing  with  l,2cS9  cases  obtained  from  the  Kegistrar-General's 
Reports  for  live  years,  finds  the  proportion  to  be  678  males 
to  611  females,  or  about  111  to  1.  The  age  of  the  patient, 
however,  has  certainly  a  conspicuous  influence  upon  this 
proportion.  The  younger  the  individual  the  more  marked 
is  the  preponderance  of  the  male  sex.  Thus,  in  twenty- 
tive  cases  in  children,  collected  by  Rilliet,  twenty-two  were 
in  male  subjects  and  three  only  in  females.  Mr.  Gay's 
statistics,  however,  are  probably  more  trustworthy.  He  shows 
that  in  children  under  one  year  old  the  proportion  of  males 
to  females  is  as  168  to  93.  As  age  advances  the  dispro- 
portion becomes  gradually  less  marked,  until  between  the 
ages  of  twenty-five  and  thirty-five  the  number  of  cases 
met  with  in  the  two  sexes  is  about  equal.  After  thirty-five 
there  appears  to  be  a  preponderance  on  the  side  of  the 
females,  the  proportion  between  the  ages  of  thirty-five  and 
/orty-tive  being,  according  to  Mr.  Gay,  as  74  females  to 
55  males. 

This  matter  appears  to  be  somewhat  influenced  also  by 
the  chronicity  of  the  case.  Thus,  out  of  fifty-one  cases  of 
chronic  invagination  collected  by  Rafinesque,  thirty-eight 
were  males  and  thirteen  females. 

Age. — Intussusception  occurs  so  frequently  in  children 
that  it  forms  the  most  common  variety  of  obstruction  to 
which  they  are  liable.  More  than  50  per  cent,  of  the  cases 
are  met  with  during  the  first  ten  years  of  life,  and  about 
25  per  cent,  during  the  first  year  of  existence.  Taking  the 
mean  of  the  somewhat  voluminous  tables  that  have  been 
published  upon  this  subject,  I  think  that  the  following  per- 
centage will  fairly  represent  the  frequency  of  the  disease 
durinof  the  various  decades  of  life : 


Before  the  age  of  11  years 
Lutween  11  and  20  years 
„  21  and  40  years 

„         41  and  60  years 
Beyond  60  years     . 


53  per  cent. 
12 

20         „ 

11 
4         „  or  probably  less. 


Taking  the  percentages  of  a  large  number  of  chronic  cases 
only  the  follo^ving  results  are  obtained  : 


350  INTUSS  USCEPTIOX. 

Before  the  age  of  11  years   .        .        .25  per  cent. 
Between  11  and  20  years      .        .        .10        „ 

„  21  and  40  years      .        .         .50        „ 

„         41  and  60  years     .        .        .11         „ 
Beyond  60  years 4        „ 

A  comparison  made  between  these  two  tables  shows  in 
a  striking  manner  the  influence  of  age  upon  the  chronicity 
of  the  case.  It  seems  to  show  the  great  frequency  of  the 
acuter  forms  during  the  Erst  ten  years  of  life,  and  of  the 
chronic  forms  during  the  period  of  active  adult  age. 

Frevious  history. — In  the  previous  history  of  cases  of 
intussusception  there  is  little  to  note  that  is  of  clinical  or 
diagnostic  interest.  Indeed,  the  only  circumstances  to  be 
considered  in  such  a  history  are  those  which  have  been  already 
described  as  concerned  in  the  etiology  of  the  disease.  Several 
cases  have  been  reported  in  which  there  is  little  doubt 
but  that  the  patients  had  had  previous  attacks  of  intus- 
susception from  which  they  recovered  more  or  less  readil}''. 
Such  a  case  was  that  of  a  child,  aged  fifteen  months,  who 
was  suffering  from  an  intussusception  that  protruded  at 
the  anus.  Since  its  birth  the  child  had  been  liable  to  attacks 
of  "  colic,"  during  which  a  mass  would  appear  in  the  epi- 
gastric region  and  subside  as  the  pain  passed  off* 

Onset. — The  mode  of  onset  is  usually  sudden.  In  acute 
and  subacute  cases  a  sudden  mode  of  onset  is  to  be  noticed 
in  about  75  per  cent,  of  the  examples. 

In  chronic  cases  the  sudden  appearance  of  symptoms  is 
noted  in  about  30  to  40  per  cent,  of  the  recorded  instances. 
The  mode  of  onset  is  somewhat  influenced  by  the  nature 
of  the  invagination.  In  ileo-colic  intussusceptions  the  com- 
mencement is  nearly  always  sudden,  while  in  the  colic  and 
rectal  varieties  it  is  more  frequently  gradual.  The  symptoms 
may  appear  during  perfect  health.  They  may  come  on 
abruptly  during  exercise  or  while  at  res  ,  and  even  during 
sleep. t  Several  cases  in  infants  displajcd  their  first  evidences 
while  the  child  was  being  suckled.  (See  the  section  on  the 
etiology   of  intussusception,  page  177.) 

As  a  rule,  in  both  the  acute  and  the  chronic  cases  the 
first  symptom  is  pain,  a  symptom  the  characters  of  which 
are  described  below.  Vomiting  is  not  usuall}'  among  the 
initial  symptoms. 

Among  the  rarer  commencing  symptoms  the  following 
n:iay  be  noted.  The  first  evidence  of  the  invagination  may 
be  simply  tenesmus  without  abdominal  pain;|  or  tenesmus 

*  J^^eiv  Yiirk  Med.  Jotirn.,  July,  1877. 

t  Path.  Soc.  Trans.,  vol.  xi.,  p.  109;  Mr.  Nimneley. 

X  Mr.  Pitts;   8t.  Thomas's  Hosp.  Rrpoits,  1S82,  p.  73. 


SYMPTOMS.  .3.j1 

with  much  straining  at  stool.  In  one  case  of  gradual  origin 
the  malady  was  ushered  in  with  slight  colicky  pains,  with 
much  tenesmus,  and  with  dysuria.*  In  at  least  one  instance 
the  first  definite  signs  of  intussusception  were  afforded  by  an 
escape  of  blood  from  the  anus,  and  shortly  afterwards  by  the 
projection  of  the  invaginated  gut  through  the  sphincter,  t 

It  by  no  means  follows  that  cases  marked  by  violent 
and  abrupt  symptoms  at  the  commencement  necessarily  take 
an  acute  course.  They  frequently  do ;  although,  on  the  other 
hand,  many  chronic  cases  have  begun  with  very  urgent 
manifestations.  As  one  instance  of  the  latter  association,  I 
might  quote  a  case  by  Hauf,t  where  the  first  symptoms 
were  those  of  pain  so  violent  as  to  cause  the  patient  to 
roll  upon  the  ground.  The  subsequent  course,  however,  of 
the  disease  was  lingering. 

The  Acute  and  the  Chronic  Forms. — Before  com- 
mencing a  notice  of  the  separate  symptoms,  a  superficial 
comparison  may  be  made  between  the  acute  and  the  chronic 
cases.  In  the  acute  form  of  the  disease  the  symptoms 
depend  mainly  upon  strangulation  of  the  invaginated  bowel 
and  actual  obstruction  of  its  lumen.  They  are  marked  by 
paroxysmal  pain,  by  tenesmus,  by  the  passage  of  bloody 
mucus,  if  not  by  diarrhoea,  and  by  the  presence  of  a  tumour. 
In  chronic  intussusception  a  patient  may  die  from  one  of 
two  conditions.  He  may  succumb,  emaciated  and  worn  out 
by  the  frequent  pain  or  vomiting  and  the  gross  interference 
with  the  functions  of  the  intestine  ;  or,  after  exhibiting  for 
some  time  the  evidences  of  chronic  invagination,  he  may  die 
of  an  acute  attack  supervening  upon  the  chronic.  In  the 
lingering  form  the  symptoms  are  usually  very  ambiguous, 
and  an  aspect  may  be  assumed  by  the  case  that  may  lack 
all  the  most  distinctive  signs  of  invagination. 

Pain. — Pain,  as  already  stated,  is  usually  the  first 
symptom  of  intussusception.  It  is  also  one  of  the  most 
constant  and  most  conspicuous.  Sometimes  the  initial  attack 
of  pain  reaches  at  once  the  maximum  of  that  felt,  and  after 
its  subsidence  the  suffering  becomes  moderate.  Usually, 
however,  the  pain  increases  gradually  in  severity  up  to  a 
certain  point,  and  then  begins  to  subside.  During  the  time 
that  the  invagination  is  increasing  and  while  the  process  of 
strangulation  is  active  the  pain  may  be  acute,  but  when  the 
parts  have  become  well  fixed  by  adhesions,  or  more  especially 
when   gangrene   has   set   in,   it   commonly    becomes  greatl}' 

*  Ohle.  ]Mag-.  fiir  die  gesam.  Heilk.  Rust.,  1817,  bd.  ii.,  s.  253. 
t  Ur.  H.  Marsh;  St.  Bart.'s  Hosp.  Reports,  1876,  p.  95. 
I  llcidelb.  mod.  Anal,  1842,  bd.  8,  s.  428. 


352  ACUTE    INTUSSUSCEPTION. 

modified  in  its  character.  This  tendency  of  the  pain  to 
become  less  at  a  certain  stage  in  the  case  is  a  conspicuous 
feature  in  intussusception.  The  pain  in  any  given  case  may 
commence  gradiiall}'-  in  the  form  of  trifling  attacks  of  colic 
appearing  at  long  intervals  or  coming  on  onl}'  after  defseca- 
tion,  or  a  violent  initial  attack  may  be  preceded  for  a  while 
by  a  definite  but  trifling  sense  of  discomfort  in  the  abdomen. 
The  form  of  invagination  that  is  most  usually  associated  with 
intense  pain  at  the  onset  is  the  ileo-colic. 

The  pain  is  colicky,  and  its  great  feature  is  its  occurrence 
in  paroxysms.  Intermittent  pain,  as  has  been  already  stated, 
nearly  always  indicates  an  incomplete  obstruction  in  the 
intestine  (page  294)  and  in  intussusception,  therefore,  it  may 
be  expected  to  be  well  marked.  The  pain  may  at  first  occur  at 
long  intervals,  during  which  the  patient  is  free  from  suffering. 
As  the  case  advances  the  intervals  become  shorter  and 
shorter.  In  the  acuter  forms  the  intervals  are  not  marked. 
The  patient  very  often  is  never  free  from  pain  ;  but  here, 
although  the  pain  is  continuous,  it  is  broken  in  upon  by 
definite  exacerbations.  The  intervals  between  the  attacks 
are  sometimes  very  precise,  the  paroxysms  appearing  every 
twenty  or  thirty  minutes,  and  having  a  more  or  less  exact 
duration.  In  any  case,  as  the  intussusceptum  becomes  con- 
gested, its  neck  more  and  more  strangulated,  and  its  lumen 
narrowed,  the  pain  becomes  more  continuous,  although  it 
is  still  associated  with  exacerbations.  When  the  paroxysms 
are  marked  they  usually  appear  suddenly  and  subside  sud- 
denly, although  to  this  circumstance  there  are  many  exceptions. 

The  pain  in  intussusception  depends  upon  violent  and 
irregular  peristaltic  movement.  It  is  more  severe,  as  a  rule, 
in  cases  involving  the  small  than  in  those  involving  the 
large  intestine.  Some  of  the  most  severe  instances  of  pain 
have  been  in  the  ileo-colic  varieties  and  in  invaginations 
high  up  in  the  small  intestine  where  the  muscular  coat  is 
well  developed.  It  has  been  said  that  the  intervals  between 
the  paroxysms  are  shorter  when  the  small  gut  is  involved, 
as  compared  with  the  colon.  This  is  often  true,  but  the 
fact  depends  rather  upon  the  greater  degree  of  occlusion 
met  with  in  the  lesser  bowel  than  upon  the  anatomical 
position  of  the  lesion.  Everything  depends  upon  the  state 
of  the  intussusception  itself  A  small  invagination  in  the 
colon  may  cause  early  and  intense  pain,  while  on  the  other 
hand  an  ileo-ceecal  invagination  may  actually  project  at 
the  anus  before  much  pain  has  been  produced. 

I  cannot  endorse  the  statement  that  the  more  empty 
the  bowel   the  less  the  pain.     Were  this  the  fact  the  least 


SYMPTOMS.  ;5r,3 

painful  cases  would  be  those  that  have  followed  upon 
diarrhoea.      The  reverse,  rather,  is  what  is  usually  met  with. 

In  a  few  cases  the  pain  has  been  described  as  agonising, 
but  as  a  rule  it  is  much  less  severe  than  in  other  forms  of 
acute  intestinal  obstruction. 

In  position  it  is  at  first  very  ill  defined,  but  as  the 
invagination  advances,  and  especially  as  a  definite  tumour 
develops,  the  pain  becomes  more  or  less  distinctly  localised 
about  the  seat  of  the  lesion. 

Vomiting'. — -Vomiting  is,  in  intussusception,  by  no  means 
so  conspicuous  a  symptom  as  it  is  in  other  forms  of  acute 
intestinal  obstruction,  such  as  in  strangulation  by  bands.  It 
does  not  appear  so  early ;  it  seldom  becomes  excessive  or 
very  distressing ;  it  is  less  often  stercoraceous,  and  is  apt  to 
fluctuate  considerably. 

Vomiting  is  more  constant  and  severer  in  acute  cases  than 
it  is  in  chronic.  In  about  three-fourths  of  the  acuter  cases 
it  appears  with  the  earliest  symptoms,  coming  on  either  with 
the  pain  or  a  little  while  after  it.  In  the  remaining  cases  it 
appears  later,  and  on  an  average  about  the  third  day.  Its 
onset  may  be  nuich  delayed,  as  in  a  case  where  laparotomy 
was  performed  on  the  eighteenth  day,  and  where  vomiting 
did  not  appear  until  the  fifteenth  day.  In  chronic  forms  the 
delay  may  be  still  greater,  and  vomiting  may  not  set  in  until 
a  few  days  or  hours  before  death.  In  about  8  per  cent, 
of  the  acute  and  subacute  cases  vomiting  does  not  appear 
to  have  occurred  at  all  during  the  course  of  the  malady. 
Vomiting  occurs  earlier  in  children  than  in  adults. 

There  is  often  great  irregularity  in  the  appearance  and 
character  of  the  sickness.  Indeed,  as  a  rule  in  intussuscep- 
tion this  symptom  is  marked  by  considerable  fluctuations. 
I  might  take  the  following  as  a  fairly  marked  instance  :  In  a 
case  of  ileo-colic  invagination,  fatal  on  the  iourteenth  dav, 
vomiting  appeared  early  with  the  initial  pain.  It  persisted 
for  five  days.  During  the  sixth  day  the  pat'ent  did  not 
vomit  at  all  ;  on  the  seventh  day  the  sickness  returned  in  a 
more  severe  form  than  ever.  On  the  eighth  it  was  again 
much  better ;  while  on  the  ninth  it  became  stercoraceous."^ 
In  many  cases  the  vomiting,  after  having  been  severe,  has 
been  absent  for  several  days  together.  In  several  examples 
of  the  acute  form  of  the  malady  that  I  have  collected 
the  patient  was  only  sick  once,  while  in  other  instances  the 
vomiting  appeared  at  long  and  irregular  intervals.  The 
attacks  of  vomiting  often  coincide  with  attacks  of  pain.  In 
one  instance  of  acute  invagination  where  the  sickness  had 

*  Bull,  de  la  Sor.  Anat.,  1867.  p.  136  ;  M.  Kaudier. 
X 


354  ACUTE    INTUSSUSCEPTION'. 

ceased,  the  symptom  was  caused  to  reappear  by  introducing 
the  finger  into  the  rectum.'^ 

The  examination  of  a  number  of  recorded  cases  shows 
that  the  vomiting  is  least  severe  and  least  constant  in  those 
cases  which  are  associated  throughout  with  diarrhoea.  It  is 
also  very  often  slight  in  degree  in  those  instances  of  the 
malady  which  are  attended  by  distinctly  paroxysmal  pain.  In 
other  words,  the  sickness  is  least  troublesome  when  the 
lumen  of  the  bowel  is  still  patent.  Most  of  the  worst 
instances  have  been  in  cases  marked  by  early  and  persistent 
constipation,  excluding  from  that  term  the  passage  of  blood 
and  mucus  unmixed  with  fseces.  In  any  case  the  sudden 
cessation  of  diarrhoea  is  usually  attended  by  an  increase  in 
the  vomiting. 

In  many  cases  the  vomiting  gives  much  temporary  relief 
This  is  especially  the  case  when  it  appears  at  long  intervals. 
This  feature  is  more  marked  in  the  vomiting  of  intussuscep- 
tion than  in  any  other  form  of  obstruction. 

The  vomited  matter  is  usually  alimentary  or  bilious. 
Stercoraceous  vomiting  is  not  met  with  in  more  than  25 
per  cent,  of  all  cases  of  acute  or  subacute  intussuseeptioiL 
In  chronic  cases  it  occurs  only  in  about  7  per  cent.  In  the 
acuter  cases  stercoraceous  vomiting  is  in  nearly  every  instance 
associated  with  constipation,  or  at  least  with  the  passage  of 
no  fsecal  matter  in  the  discharge  from  the  anus.  It  is  met 
with  most  I'requently  in  invaginations  about  the  ileo-csecal 
region,  and  then  in  those  involving  the  lower  extremity  of 
the  small  intestine.  It  appears,  on  an  average,  on  the  fourth 
or  fitth  day.  It  often,  however,  does  not  appear  ior  a  week 
or  a  fortnight,  or  not  until  near  the  termination  of  the  case, 
when  the  progress  of  the  malad}^  is  distinctly  subacute.  In 
two  or  three  instances  blood  has  appeared  in  the  vomited 
matter.  This  symptom  is  usuall}^  met  with  in  children  and 
in  enteric  intussusceptions. 

On  the  whole,  it  may  be  said  that  vomiting  is  most 
marked  with  the  enteric  and  ileo-colic  invaginations,  less 
marked  in  the  ileo-caical  forms,  and  least  conspicuous  in  the 
colic  and  rectal  varieties. 

The  State  of  the  Bowels. — The  state  of  the  bowels  in 
intussusception  presents  some  very  distinct  characters.  As  a 
result  of  the  violent  peristaltic  action  excited  by  the  invagina- 
tion, diarrhcea  is  a  very  common  condition;  and  as  a  consequence 
of  the  great  engorgement  of  the  intussusceptum  it  happens 
that  the  motions  passed  are  usually  stained  with  blood.  When 
the  lumen  of  the  bowel  becomes  so  occluded  that  no  more 

*  Lancet,  vol.  i.,  1877,  p.  273  ;  Mr.  Kansford. 


SYMPTOMS.  355 

focal  matter  passes,  the  evacuations  may  consist  simply  of 
bloody  mucus. 

Constipation,  as  indicated  by  the  passao^e  of  no  fsecal 
matter,  is  not  common  in  intussusception.  In  the  majority 
of  the  acute  and  subacute  cases,  there  is  some  diarrhoea  at 
first  and  then  absolute  constipation  towards  the  termination 
of  the  case.  The  occurrence  of  more  or  less  constipation  as  a 
marked  feature  during  the  progress  of  the  malady  does  not 
pertain  to  more  than  80  per  cent,  of  the  cases.  Sometimes 
diarrhoea  continues  throughout  the  whole  course  of  the  case, 
being,  as  a  rule,  more  marked  at  the  commencement  than  the 
end.  At  the  same  time,  it  may  be  noticed  that  a  severer 
diarrhcea,  or  a  diarrhoea  after  constipation,  may  precede, 
attend,  or  follow  the  elimination  of  a  gangrenous  intussuscep- 
tum.  When  gangrene  is  in  progress  the  smell  of  the  stools  is 
peculiarly  offensive  and  is  described  by  some  as  "carrion-like." 
Sometimes  a  loose  state  of  the  bowels  alternates  with  some 
constipation,  but  this  condition  is  more  usual  in  the  chronic 
forms  of  the  malady.  The  diarrhoea  may  be  severe;  and  from 
ten  to  twenty  evacuations  may  pass  in  the  twent)'-four  hours. 

The  occurrence  of  blood  in  the  stools  is  a  striking  feature. 
As  a  rule,  the  more  acute  the  case  and  the  more  violent  the 
strangulation,  the  more  conspicuous  is  the  haemorrhage.  In 
acute  cases  this  symptom  is  present  in  about  80  per  cent, 
of  the  examples.  It  is  met  with  less  frequently  in  those 
following  a  subacute  course,  and  is  found  in  no  more  than  50 
per  cent,  of  the  chronic  cases.  It  is  perhaps  more  marked  m 
children  than  in  adults.  It  is  inost  constant  in  the  ileo-colic 
varieties,  then  in  the  ileo-csecal,  next  in  the  colic,  and  is. 
probably  least  constant  in  enteric  invaginations.  The  amount 
of  blood  is  Tisually  not  excessive.  The  hannorrhage  may, 
however,  be  so  profuse  as  to  be  the  principal  cause  of  death.^ 
As  already  observed,  the  clots  of  blood  may  block  up  the 
lumen  of  the  intussusceptum  and  may  even  plug  the  bowel 
below  the  seat  of  the  invagination.  In  any  case,  the  symptom 
is  usually  more  marked  at  the  commencement  of  the  attack 
than  during  its  later  progress.  Bleeding  may,  however,  attend 
the  evacuation  of  the  intussusceptum. 

Constitutional  Symptoms. — Of  the  general  constitutional 
condition  of  the  patients  suffering  from  acute  and  subacute 
intussusception  little  need  be  said.  The  condition  is  nearly 
the  same,  although  differing  a  little  in  degree,  as  that  met 
with  and  described  in  connection  with  strangulation  by  bands. 

Collapse  is  usually  much  less  marked,  because  on  the  whole 

*  liC  Moj^ne,  loc.  cit.,  p.  23.      jWed.  'Times  and  Gazette,  vol.  ii.,  I860,  p.  195. 
Amer.  Joiirn.  Med.  Sciences,  vol.  xii.,  p.  372. 


356'  ACUTE    INTUSSUSCEPTION. 

the  progress  of  the  case  is  less  acute  and  the  pain  less  severe 
than  in  obstruction  by  bands.  In  some  ultra-acute  cases 
collapse  may  appear  early,  be  very  pronounced,  and  lead  on  to 
death.  This  is  especially  the  case  with  acute  invagination  in 
young  infants.  Leichtenstem  has  only  been  able  to  collect 
five  instances  of  death  during  the  first  twenty-four  hours,  and 
of  these  cases  no  less  than  foiu^  were  in  infants  not  over  one 
year  old.  I  have  alluded  to  a  case  in  dealing  with  the 
prognosis  in  Avhich  death  took  place  in  nine  hours  (page  380). 

As  regards  the  temperatv.re,  it  will  be  below  normal  in 
cases  associated  with  shock.  In  the  majority  of  the  cases, 
and  especially  in  such  as  are  subacute,  it  is  normal  or  a  little 
above  normal.  It  is  important  to  recognise  the  fact  that  there 
may  a  be  rise  of  temperature  in  intussusception  apart  from  any 
evidences  of  local  peritonitis.  As  a  good  illustration  of  this 
may  be  cited  a  case  recorded  by  Dr.  Eastes.  It  concerned  a 
little  girl  aged  eleven.  On  the  seventh  and  eighth  day  of  the 
symptoms  the  temperature  reached  101  •3.  On  the  evening  of 
the  eighth  day  the  invagination  was  reduced  by  means  of 
forced  enemata.  On  the  ninth  day  the  temperature  was  97 "6, 
The  child  made  a  good  recovery. 

Thirst  is  by  no  means  so  frequently  complained  of  in 
invagination  cases  as  it  is  in  examples  of  strangulation 
by  bands.  This  circumstance  depends  mainly  upon  the  less 
copious  character  of  the  vomiting.  When  the  vomiting  is  very 
profuse  in  intussusception  much  thirst  may  be  complained  of. 
The  symptom,  however,  in  a  marked  form  is  quite  rare. 

The  quantity  of  urine  passed  may  be  diminished,  for  the 
same  reasons  that  obtain  in  other  forms  of  acute  obstruction 
of  the  bowels.  The  symptom  is  rarely  present,  and  is  seldom, 
if  ever,  so  marked  as  in  examples  of  strangulation  by  band. 
It  is  limited  to  the  more  distinctly  acute  instances  of  the 
malady  when  it  does  occur. 

I  can  only  find  two  instances  of  intussusception  where 
strangury  was  complained  of,  and  no  case  associated  with 
the  appearance  of  cramps  in  the  limbs. 

In  the  subacute  cases  the  patients  become  thin  and 
ansemic  and  often  much  wasted.  A  condition  readily  induced 
by  the  continued  digestive  disturbance,  the  frequent  attacks 
of  vomiting  and  pain,  the  loss  of  appetite,  and  the  broken  rest. 

Tenesmus  is  a  striking  symptom.  It  is  more  commonly 
met  with  in  acute  and  subacute  than  in  chronic  cases. 
Indeed,  other  things  being  equal,  the  more  chronic  the  case 
the  less  frequent  is  the  appearance  of  the  symptom.  I  find 
that  in  acute  and  subacute  forms  tenesmus  occurs  in  about 
55  per  cent,  of  the  examples.     Rafinesque  finds  an  account 


S  YMF  TOMS.  357 

of  the  occurrence  of  this  symptom  in  only  18  per  cent,  of 
distinctly  chronic  cases.  The  mean,  therefore,  for  all  forms 
of  invagination  would  be  about  24  per  cent.  Leichtenstem 
in  his  able  monograph  gives  this  mean  as  17-6  per  cent,  but 
I  cannot  help  thinking  that  this  percentage  is  much  too  low. 
It  must  be  remembered  that  in  many  accounts  of  invagina- 
tion reported  from  a  pathological  point  of  view  the  symptoms 
are  often  imperfectly  given ;  and  many  of  such  cases  can 
hardly  but  be  included  among  Leichtenstern's  statistics. 
The  frequency  and  severity  of  the  tenesmus  depend  mainly 
upon  the  nearness  of  the  intussusception  to  the  anus.  The 
symptom  therefore  is  very  usual  in  rectal  and  colic  invagina- 
tions, is  common  in  the  more  extensive  ileo-csecal  varieties, 
and  is  least  often  met  with  in  the  pure  enteric  forms. 
Leichtenstem  finds  ninety-four  cases  marked  by  tenesmus  to 
be  thus  divided :  enteric  form,  four ;  ileo-ctecal  forms,  seventy 
five  ;  colic  forms,  fifteen.  The  proper  value  of  these  figures 
can  be  appreciated  by  reference  to  the  table  showing  the 
relative  frequency  of  the  various  varieties  (page  145). 

Tenesmus  is  usually  an  early  symptom  of  intussusception, 
and  is  indeed  often  among  its  first  manifestations.  It  may 
be  so  constant  and  so  severe  as  to  cause  intense  distress, 
as  in  a  case  reported  by  Dr.  Ballard."^  When  the  invagination 
occupies  the  rectum  or  sigmoid  flexure  the  tenesmus  may 
be  followed  by  paralysis  of  the  sphincter  ani,  whereby  a 
patulous  condition  of  the  anus  is  produced.  A  good  example 
of  this  complication  has  been  placed  upon  record  by  Mr. 
Holmes.  It  occurred  in  a  man  aged  forty,  who  had  a  rectal 
invagination.  The  sphincter  became  so  relaxed  that  several 
fingers  could  be  introduced  into  the  anus.t 

The  Condition  of  the  Abdomen. — Tension  of  the 
ahdominal  tvcdls  is  not  met  with  in  intussusception,  or,  at 
least,  not  in  the  earlier  stages.  It  appears  when  local  or 
general  peritonitis  develops,  and  may  be  present  during  the 
attacks  of  pain,  especially  when  they  have  existed  for  some 
time  and  are  attended  by  tenderness  on  pressure. 

Meteorism  is  also  rare  in  these  cases.  In  a  marked  form 
it  is  seldom,  if  ever,  met  with.  It  depends  very  largely  upon 
the  condition  of  the  bowels.  It  is  found  in  instances  where 
constipation  exists  and  where  the  lumen  of  th«  intestine  is 
practically  occluded.  It  is  thus  most  commonly  met  with 
towards  the  end  of  the  attack.  When  diarrhoea  exists,  not 
only  is  no  meteorism  present,  but  the  abdomen  is  often,  on 
the  contrary,  distinctly  sunken  in.     On  the  cessation  of  the 

*  Path.  Soc.  Trans.,  vol.  xyiji..  lS67,.p.  92, 
t  Ibid..  \iA.  viii.,  p.  177. 


358  ACUTE    INTUSSUSGEFTIOK. 

diarrbtjea,  the  sympt(iiu  may  develop.  It  is  usually  quite 
moderate  in  degree.  It  is  needless  to  say  that  it  appears  to  a 
greater  or  less  extent  when  peritonitis  sets  in. 

Local  Tenderness. — At  first  the  abdominal  parietes  are  not 
tender  on  pressure,  and  are  flaccid,  or,  at  least,  not  in  a  state 
of  tension.  It  often  happens,  indeed,  that  pressure  over  the 
more  painful  part  relieves  the  patient's  suffering.  In  intus- 
susception the  abdomen  in  time  usually  becomes  somewhat 
tender  on  pressure,  especially  about  the  site  of  the  invagina- 
tion. This  is  partly  the  result  of  continued  irregular  muscular 
action,  but  is  perhajDS  in  a  greater  extent  due  to  the  engorge- 
ment of  the  invaginated  parts  and  the  development  of  some 
local  peritonitis.  A  well  localised  tenderness  is,  in  the  absence 
of  a  definite  tumour,  a  valuable  guide  to  the  position  of  an 
intussusception.  Sometimes  the  pain  has  been  relieved  when 
the  patient  has  assumed  a  peculiar  posture.  The  longer  the 
case  lasts  the  greater  is  the  tendency  for  both  the  pain  and 
the  tendernes.-,  to  become  diffused,  presuming  that  they  have 
been  previously  more  localised. 

The  "  sigve  de  Dance"  is  of  little  or  no  value.  It  is  said 
to  be  met  with  in  cases  where  the  caecum  has  become  invagin- 
ated, as  in  the  ileo-csecal  forms  of  the  disease,  and  consists  in 
a  depression  about  the  right  flank  or  right  iliac  fossa.  It  is  sup- 
posed to  indicate  the  displacement  of  the  caput  coli.  One  would 
expect  this  symptom  to  be  more  marked  in  chronic  cases,  yet 
out  of  fifty-three  examples  of  this  form  collected  b}^  Ratinesque 
the  "  signe  de  Dance  "  was  only  noted  in  two  instances. 

An  abdominal  tumour. — The  presence  of  a  tumour 
formed  by  the  invaginated  mass,  and  to  be  felt  either  through 
the  abdominal  parietes  or  rectum  is  of  great  diagnostic  value 
in  cases  of  intussusception.  It  is  to  be  discovered  in  a  little 
less  than  50  per  cent,  of  all  cases,  and  would  appear  to  be 
not  more  frequently  felt  in  the  chronic  than  in  acute  forms. 
Thus  Leichtenstern,  taking  all  varieties  of  intussusception, 
found  that  it  was  met  with  222  times  in  a  total  of  433  cases. 
Rafinesque,  dealing  only  with  chronic  cases,  found  24  exam- 
ples of  the  occurrence  of  a  tumour  in  53  recorded  instances. 

The  tumour  is  more  commonly  met  with  in  some  ana- 
tomical forms  of  invagination  than  in  others.  It  is  most 
frequently  associated  with  the  ileo-caecal  and  colic  varieties, 
least  frequently  with  the  enteric  and  ileo-colic.  The  relative 
frequency  in  the  different  varieties  may  be  expressed  as 
follows : — In  the  ileo-ca3cal  form  it  occurs  in  61  per  cent,  of 
the  cases;  in  the  cohc  in  52  per  cent.;  in  the  enteric  in 
24  per  cent. ;  and  in  the  ileo-colic  in  23  per  cent. 

It  is  usuall}'  more  distinct  in  children  than  in  adults. 


SYMPTOMS.  359 

The  tumour  varies  in  size.  It  may  be  as  small  as  a  hen's 
egg,  or  it  may  attain  the  thickness  of  the  adult  fore-arm. 
It  is  cylindrical,  and  is  very  commonly  described  as  sausage- 
shaped.  It  often  shows  the  distinct  curve  of  the  intussuscep- 
tion. As  regards  length,  it  is  usually  short  and  very  rarely 
exceeds  six  inches.  This  limitation  in  length  does  not 
necessarily  correspond  to  the  length  of  the  invagination  mass. 
It  depends  rather  upon  its  position.  The  tumour  is  not 
evident  when  it  occupies  the  hepatic  or  splenic  Hexures  of  the 
colon,  and  thus  the  portion  that  can  be  detected  cannot  well 
exceed  the  length  of  the  transverse  or  descending  colon,  or  of 
part  ot  the  right  limb  of  the  large  bowel. 

It  has  assumed  the  appearance  of  a  double  tumour,  one 
part  having  been  felt  in  the  transverse  and  the  other  in 
the  descending  colon,  the  intermediate  portion  in  the  splenic 
flexure  not  being  evident.  In  the  ileo-csecal  variety  the 
tumour  will  be  more  distinct  the  nearer  the  mass  is  to 
the  rectum.  While  in  the  ca3cum  and  lower  ascending 
colon  the  tumour  must  necessarily  be  small.  The  rarity  of 
a  tumour  in  the  ileo-colic  variety  is  explained  by  the  small 
size  of  those  invaginations  when  simple,  and  by  the  fact  that  the 
intussusceptum  is  composed  of  small  intestine  enclosed  in  large. 

It  thus  happens  that  the  tumour  is  most  often  met  with 
over  the  descending  colon,  and  next  in  frequency  over  the 
transverse  colon.  Enteric  invaginations  usually  form  a 
tumour  in  the  c«cal  region,  the  lower  ileum  being  the  part 
most  often  involved. 

The  tumour  varies  in  distinctness,  and  it  is  seldom  that  all 
parts  of  it  can  be  equally  well  made  out.  It  usually  appears 
fixed.  It  may  often,  however  especially  in  chronic  cases, 
be  observed  to  change  its  position,  now  to  advance  along 
the  colon  in  the  direction  of  the  anus,  and  now  to  return 
by  the  inverse  direction.  It  can  often  be  made  to  move 
under  the  use  of  enemata,  the  mass  being  forced  back 
towards  the  ca3cum.  This  can  only  occur  in  invaginations 
that  involve  the  colon. 

The  progress  of  the  invagination  from  the  csecum  to  the 
rectum  can  often  be  distinctly  watched.  A  tumour  that 
remains  long  stationary  in  the  csecal  region  probably  depends 
upon  an  ileo-colic  invagination. 

In  consistence  the  tumour  feels  hard  and  resisting.  Its 
density  may  vary  greatly.  During  attacks  of  pain  it  may  be 
large,  prominent,  and  hard.  During  the  intervals  it  often 
becomes  less  distinct  and  softer.  When  first  noticed  it 
frequently  happens  that  it  is  only  present  while  painfid 
peristaltic  movements  are  going  on,  being  quite  absent  Avhen 


360 


ACUTE    INTUSSVSCEFTION. 


the  patient  is  free  from  pain.  When  it  has  existed  for  some 
time  it  is  generally  tender ;  but  in  earlier  periods  any  pain 
that  may  be  felt  in  it  is  often  relieved  by  pressure.  In 
any  doubtful  case  an  examination  of  the  abdomen  should 
be  made  under  chloroform. 

M.  Homolle  reports  a  case  where  three  invaginations 
existed  in  the  small  intestine,  Avhich  gave  rise  to  three 
separate  tumours.^ 

The  importance  of  the  abdominal  tumour  in  the  diagnosis 
of  the  affection,  and  in  attempts  to  estimate  the  condition 
of  the  involved  segment,  is  considerable. 

In  no  case  should  a  tumour  be  pronounced  as  absent 
until  the  abdomen  has  been  examined  during  a  paroxysm 
of  pain.  When  present,  the  exact  site  of  the  swelling  should 
be  noted,  its  size,  its  outline,  and  its  mobility. 

It  is  especially  to  be  observed  whether  the  mass  increases 
in  size  during  attacks  of  pain,  whether  it  changes  its  position 
during  attacks  of  pain,  and  whether  it  is  tender  on  pressure. 

The  following  table  from  Leichtenstern's  monograph  will 
show  the  relation  between  the  tumour  and  the  different 
forms  of  intussusception,  together  with  the  comparative 
frequency  of  the  mass  in  different  situations. 


Seat  of 

Intussusception. 

Seat  of  Tumoue. 

CJ 

^ 

1  ^ 

u 

a 

fe 

•-3 

O  o3 

f~i 

'c 

o 

C3 

0 

9 

o 

8 

4 

5 

Csecal  region 

9 

27 

Region  of  ascending  colon 

1 

2 

1 

0 

3 

7 

Transverse  colon 

12 

2 

4 

0 

1 

19 

Region  of  descending  colon    . 

12 

4 

2 

1 

1 

20 

Region  of  sigmoid  flexure 

25 

10 

3 

2 

12 

52 

Tumour  in  the  rectum    .... 

10 

10 

0 

1 

10 

31 

Tumour  projecting  from  anus 

20 

12 

0 

1 

8 

41 

Tumour  in  hypogastrium 

0 

0 

3 

0 

0 

3 

Moving   of   tumour   from   ascending  to 

transverse  colon 

1 

0 

0 

0 

0 

1 

Moving  of  tumour  from  transverse  colon 

to  sigmoid  flexure     .... 

8 

0 

0 

0 

0 

8 

jSIoving  of  tumour  from  caecum  to  sig- 

moid flexure 

2 

0 

0 

0 

0 

2 

Site  of  tumour  unknown 

0 

1 

4 

0 
9 

4 

44 

9 

Total         .        .         .        . 

100 

41 

26 

220 

*  Bull,  de  la  Sou.  Anat.,  1870,  p.  260. 


SYMPTOMS.  361 

A  Tumour  in  the  Rectum. — It  will  be  seen  from  the 
above  table  that  in  thirty-one  instances  the  tumour  was  felt 
in  the  rectum,  while  in  forty-one  it  projected  from  the  anus. 
This  condition  is,  as  may  be  surmised,  almost  limited  to 
the  colic  and  ileo-csecal  invaginations.  It  appears  much 
more  frequently  in  children  than  in  adults.  In  children, 
moreover,  the  tumour  reaches  the  rectum  much  more 
quickly,  owing  to  the  greater  mobility  of  a  child's  colon. 
In  such  patients  it  has  reached  the  rectal  region  by  the 
second  day  of  the  attack,  and  may  be  as  already  stated, 
one  of  the  early  evidences  of  the  invagination.  As  a  rule, 
the  tumour  appears  much  later,  on  an  average  (in  acute  and 
subacute  cases)  on  the  seventh  day.  In  chronic  forms  the 
average  date  for  the  appearance  of  the  mass  in  the  rectum  is 
the  fifteenth  day.  It  has,  however,  appeared  as  late  as  the 
third  and  fourth  months,  and  in  one  case  as  late  as  the 
seventh  month  of  the  duration  of  the  symptoms. 

The  protrusion  is  usually  small  (being  about  three  inches 
in  length),  and  conical  in  shape.  It  may  attain  greater 
length  (I  have  seen  one  eight  inches  long),  and  cases  are 
reported  Avhere  ten  and  twelve  inches  of  bowel  have  projected 
from  the  anus.  The  protruding  mass  is  usually  deeply  con- 
gested and  much  altered  in  structure.  It  may  be  gangrenous. 
The  intussusception  has,  however,  been  successfully  reduced 
by  enemata,  insufflation,  or  laparotomy,  even  when  it  has 
protruded  for  some  time  at  the  anus."^  The  projecting 
tumour  may  present  at  its  apex  the  ileo-cfecal  valve,  and 
near  its  extremity  the  orifice  of  the  appendix.  When 
examined  by  the  finger  introduced  into  the  rectum,  the 
tumour,  before  it  has  prolapsed,  presents  tolerably  character- 
istic features  to  the  touch.  Its  swollen  extremity  with  its 
narrowed  lumen  has  been  many  times  compared  to  the  os 
uteri,  and  the  comparison  is  a  very  suitable  one. 

The  tumour  when  in  the  rectimi,  or  when  protruding 
beyond  it,  has  been  on  several  occasions  the  cause  of  an  error 
in  diagnosis.  It  has  been  mistaken  for  prolapse,  for  rectal 
polyp,  and  for  piles.  Unfortunately  the  error  has  extended 
from  the  diagnosis  to  the  treatment,  and  the  mass  has  been 
incised  or  cauterised  and  even  cut  oft'.  There  are  some  re- 
markable cases  of  recovery  after  these  operations.  In  one 
the  patient  was  a  man  aged  sixty,  and  the  tumour,  prolapsed 
beyond  the  sphincter,  was  taken  for  a  polyp  or  a  cancerous 

*  The  best  case  is  the  well  l^novvn  one  of  JNIr.  Hutchinson's.  Here  the 
symptorus  had  lasted  one  month  and  the  prolapse  had  existed  for  fifteen  days. 
The  bowel  was  reduced  after  laparotomy,  and  the  child  recovered.  Med.-Chir. 
Trans,,  vol.  Ivii. ,  p.  31. 


362  ACUTE    INTUSSUSGEFIION. 

growth.  It  was  removed  en  masse  by  the  galvanic  wire  and 
found  to  be  a  piece  of  greatly  hypertrophied  ileum  with  the 
ileo-C8ecal  valve.  The  patient  recovered,  and  was  relieved  oi 
a  constipation  from  which  he  had  long  suffered.*  In  another 
case,  in  the  person  of  a  child  aged  fifteen  months,  four  inches 
of  intussuscepted  bowel  were  cut  away  at  the  anus  without 
any  evil  following.t  In  a  third  instance  the  tumour  was 
considered  to  be  "  hsemorrhoidal,"  and  was  incised  to  the 
extent  of  one  inch,  laparotomy  was  then  performed,  the  in- 
tussusception reduced,  and  the  wound  in  the  colon  stitched 
up.     The  patient  died. J 

On  the  other  hand,  in  cases  of  intestinal  obstruction 
tumours  have  been  found  in  the  rectum  that  haye  been 
mistaken  for  invaginated  masses.  Thus,  in  a  case  reported 
by  Dr.  Piatt,  a  child  aged  nine  had  symptoms  of  obstruction 
associated  with  some  of  the  signs  of  intussusception.  High 
up  in  the  rectum  a  defined  soft  and  elastic  swelling  could  be 
I'elt  which  had  an  orifice  like  the  os  uteri.  In  a  few  days  it 
was  found  to  be  a  little  lower  down.  The  child  died.  The 
autopsy  revealed  a  stricture  of  the  small  intestine  but  no 
invagination.  The  tumour  was  a  remarkable  false  diverti- 
culum in  the  rectal  wall,  into  the  orifice  of  which  the  finger 
had  been  passed.  §  In  another  case,  in  a  boy  aged  thirteen 
there  was  an  intussusception  of  the  ileum.  Laparotomy  was 
performed  w^ith  a  fatal  result.  During  life  there  was  felt  in 
the  rectum  "  a  soft  velvety  but  resisting  body  with  a  small 
central  depression,  suggestive  of  the  os  uteri.  Around  this, 
and  between  it  and  the  rectum  Avail,  the  finger  could  be 
swept  freely,  and  the  injection  tube,  when  guided  by  the 
finger,  could  be  passed  upwards  for  a  few  inches."  The 
autopsy  revealed  an  invagination  in  the  ileum  nine  inches 
from  the  caecum,  while  the  rectal  tumour  was  simply  a  mass 
of  firm  blood-clot.  II     The  case  is  reported  by  Mr.  H.  Morris. 

I  can  only  find  two  cases  among  the  acute  or  subacute 
forms  of  i]itussusception  where  coiU  of  intestine  were  visible 
through  the  abdominal  parietes.  One  instance  occurred 
in  Mr.  Morris's  patient,  to  whose  case  allusion  has  just 
been  made.  The  feature  was  noticed  on  the  sixth  day  of 
the  attack,  the  patient  dying  on  the  eighth.  The  other 
instance  concerned  a  case  of  ileo-colic  invagination  in  a  girl 
aged  seventeen.^     The  symptom  appears  to  have  been  first 

*  Boston  Med.  Jo'urn.,  July  6,  1876. 
t  New  Yorli  Med.  Journ.,  July,  1877. 
+  Mag.  fiir  gesam.  Heilk.  Rust.,  s.  253.     Berlin,  1817. 
§  Lancet,  vol.  i.,  1873,  p.  42. 

il  Path.  Soc.  Trans.,  vol.  xxviii.,  p   131 ;  Mr.  Henry  ^lorris. 
H  Bull,  de  la  .Soc.  Anat.,  1867,  p.  136. 


SYMPTOMS.  363 

noticed  on  the  eleventh  day,  death  taking  place  on  the 
fourteenth.  It  is  worthy  of  note  that  this  patient  was 
emaciated  by  chronic  phthisis  at  the  time  of  the  attack. 

4.  Acute  Obstruction  by  Gall  Stones,  Foreign  Bodies, 
E'rc. — The  principal  form  of  acute  obstruction  met  with  under 
this  heading  depends  upon  gall  stones.  It  will  therefore  be 
convenient  to  select  obstruction  by  gall  stones  as  typical  of 
the  present  series  of  cases.  At  the  end  of  the  section  notice 
Avill  be  taken  of  acute  obstruction  by  foreign  bodies  and  by 
enteroliths. 

Acute  Obstruction  by  Gall  Stones. — It  must  be  dis- 
tinctly understood  that  the  great  majority  of  gall  stones  are 
passed  along  the  intestine  without  producing  any  symptoms, 
and  that  many  in  their  passage  cause  but  insignificant 
symptoms.  In  other  instances  the  stone  remains  in  the 
intestine  quiescent  for  a  long  time,  or  induces  some  colic  with 
occasional  vomiting  and  some  constipation ;  and  in  another 
set  of  cases  evidences  of  chronic  obstruction  are  produced. 

A  volvulus  of  the  small  intestines  may  follow  upon  the 
contortions  induced  by  the  passage  of  a  large  gall  stone 
through  the  small  intestine.  Mayo  Robson  gives  two  ex- 
amples of  this  exceedingly  uncommon  condition.  One  patient 
was  a  woman  of  sixty-eight,  who  exhibited  the  symptoms  ol 
acute  intestinal  obstruction,  and  upon  whom  laparotomy  was 
performed  on  the  eighth  day  of  the  obstruction.  A  volvulus 
of  the  small  intestine  was  discovered  and  untwisted.  Eight 
days  after  laparotomy  a  gall  stone  three  inches  in  circum- 
ference was  passed  by  the  rectum. 

The  second  patient  was  a  woman  aged  sixty-two,  who  was 
suffering  from  acute  intestinal  obstruction,  and  upon  whom 
laparotomy  was  performed  on  the  sixth  day.  She  had  had 
several  attacks  of  hepatic  colic,  some  of  which  had  been 
attended  by  jaundice.  Coils  of  intestine  in  movement  were 
visible  through  the  parietes.  A  volvulus  of  the  lesser  bowel 
was  discovered  and  untwisted ;  the  patient  did  well.  In 
both  these  patients  there  was  a  well-marked  localised  swell- 
ing near  the  umbilicus  which  became  hard  during  the 
paroxysms  of  pain. 

In  a  few  examples  the  biliary  calculus  may  cause  acute 
obstruction,  due  to  the  actual  blocking  of  the  bowel  by  the 
stone.  In  such  cases  it  will  be  found  lodged  in  the  duo- 
denum, jejunum,  or  more  usually  in  the  lower  ileum.  It  is 
with  this  form  of  gall  stone  obstruction  that  the  present 
section  is  alone  concerned. 

Intestinal  obstruction  due  to  gall  stones  is  comparativel}' 


364         ACUTE    OBSTRUCTION   BY    GALL    STONES. 

rare,  althougli  Schilller^"  has  collected  one  hundred  and 
thirty-nine  examples  of  this  accident. 

Sex.  and  Age. — The  condition  is  much  more  common  in 
females  than  in  males.  Among  Schtiller's  cases  only  2 5 -9 
per  cent,  are  in  men. 

The  great  majority  of  the  patients  are  beyond  middle 
age,  most  of  the  cases  falling  between  the  ages  of  fifty  and 
seventy.  Indeed  no  less  than  75  per  cent,  of  the  instances 
are  in  patients  over  fifty.  Among  Schtiller's  cases  the 
extremes  in  the  niatter  of  age  are  respectively  eighteen  and 
ninety-four  years. 

Previous  History. — In  many  of  the  cases  there  has  been 
no  history  of  hepatic  colic ;  in  others  there  have  been  such 
attacks,  which  depended,  however,  most  probably  upon  the 
passage  of  smaller  calculi  previous  to  the  entrance  into  the 
bowel  of  the  large  stone  which  caused  obstruction.  There 
are  instances  where  the  patient  was  practically  free  from  any 
abdominal  symptoms  up  to  the  time  of  the  tinal  obstructive 
attack.  Dr.  W.  H.  Draper  has  recorded  an  excellent  example 
of  this  circumstance.t  On  the  other  hand  are  examples 
showing  evidence  of  local  peritonitis  in  the  vicinity  of  the 
gall  bladder  and  associated  with  symptoms  which  may  be 
very  properly  ascribed  to  the  passage  of  the  stone  direct 
from  the  bladder  into  the  duodenum.  These  symptoms 
are  usually  marked  by  a  more  or  less  acute  abdominal  dis- 
turbance marked  by  severe  pain  in  the  hepatic  region  asso- 
ciated with  tenderness.  There  may  or  may  not  be  jaundice. 
There  will  be  some  rise  of  temperature,  together  with  vomit- 
ing, constipation,  meteorism,  and,  indeed,  the  usual  phenomena 
of  local  peritonitis.  On  the  other  hand  the  symptoms  due  to 
the  escape  of  the  stone  by  ulceration  into  the  duodenum,  or 
colon,  may  be  quite  slight,  and  may  be  well  mistaken  for  an 
attack  of  hepatic  colic.  I  have  met  with  instances  in  which 
there  had  been  such  a  passage  of  the  stone,  but  in  which 
there  was  no  single  circumstance  in  the  patient's  history  to 
indicate  when  the  calculus  had  effected  the  fistulous  com- 
munication. 

As  to  the  length  of  time  which  may  elapse  between 
the  passage  of  the  calculus  into  the  gut  and  the  appear- 
ance of  obstructive  symptoms  there  is  little  to  be  said 
definitel}^  owing  to  the  uncertainty  which  may  surround 
the  exact  period  at  which  the  stone  entered  the  bowel. 

As  a  rule  calculi  produce  intestinar  trouble  within  a  few 
days  of  reaching   the   bowel.      Obstructive   symptoms    may 

*  Gallensteine  als  Ursache  des  Darmobstruction.     Strassburg-,  1891. 
f  JVov  York  Med.  Journ.,  vol.  xxxvi.,  1882,  p.  17. 


SYMPTOMS.        .  '.](',r, 

follow  close  upon  tlie  inflaiumatory  phenomena  which  mark 
the  passage  of  the  stone  from  the  biliary  passages  by  ulcera- 
tion. I  was  called  to  see  an  old  gentleman  of  over  seventy 
years  of  age  who  had  been  laid  up  in  bed  for  four  weeks. 
During  all  this  time  he  had  exhibited  the  symptoms  of 
severe  local  peritonitis  about  his  gall  bladder.  The  local 
symptoms  were  such  as  to  make  it  probable  that  some 
suppuration  had  taken  place.  There  was  fever  and  occa- 
sional vomiting,  but  no  jaundice.  A  considerable  mass  could 
be  felt  under  the  liver.  It  was  fi.xed  and  tender.  There 
was  a  well-marked  history  of  gall  stones.  After  the  peri- 
toneal symptoms  just  described  had  lasted  some  three  weeks 
they  exhibited  a  sudden  improvement.  The  pain,  tender- 
ness, and  swelling  became  less,  the  fever  abated,  and  it 
became  more  than  probable  that  the  gall  stone  had  entered 
the  bowel.  This  probability  was  realised,  because  almost 
immediately  after  this  period  of  relief  the  patient  was  seized 
with  symptoms  of  subacute  intestinal  obstruction,  which 
passed  away  within  a  week.  It  was  after  this  that  I  saw  him. 
The  mass  below  the  liver  presented  evidences  of  suppura- 
tion, and  I  incised  it,  evacuating  a  large  and  irregular 
abscess  cavity  beneath  the  liver,  in  which  were  lodged 
several  laro'e  srall  stones.  There  was  no  doubt  but  that  the 
abscess  was  intermediate  between  the  biliary  passages  and  the 
bowel,  and  that  into  the  bowel  one  stone  had  already  passed. 

A  case  somewhat  akin  to  this  is  reported  by  Dr.  Carrard."^ 
The  patient  was  a  woman  aged  fifty-iour,  who  six  weeks 
before  an  attack  of  intestinal  obstruction,  which  ended  in 
death,  had  had  an  abscess  opened  in  the  right  hypo- 
chondrium,  which  was  supposed  at  the  time  to  have  been 
connected  with  the  liver. 

The  interval  between  the  probable  entrance  of  the  stone 
into  the  gut  and  the  onset  of  obstructive  symptoms  may  be 
considerable.  In  a  case  reported  by  Dr.  Bradbury  f  the 
symptoms  of  local  peritonitis  about  the  gall  bladder  were 
noted  on  September  24th,  but  the  phenomena  of  obstruction 
did  not  appear  until  November  11th.  The  gall  stone  had 
made  its  way  into  the  duodenum  by  ulceration,  and  was 
impacted  in  the  jejunum.  Leichtenstern  states  that  so 
long  a  period  as  three  years  may  elapse  between  the  intro- 
duction of  the  stone  into  the  intestine  and  the  development 
of  obstructive  symptoms. 

*  R  viie  Med.  (le  la  Suisss  Roniande,  No.  2,  1SS2. 

t  Brit.  Med.  Journ.,  Sept.,  1897,  p.  79G.  Sec  aLso  a  case  by  Dr.  Taylor, 
in  which  ihe  interval  appears  to  have  been  three  months ;  Lancet,  Apvil  6th, 
1895. 


mCi  ACUTE    OBSTBTJCTION   BY    GALL    STOXES. 

Mr.  Eve  reports  a  case  in  wliicli  the  calculus  is  assumed 
to  have  remained  in  the  bowel  for  ten  years,  and  in  one 
of  Mr.  Smith's  cases  the  stone  is  believed  to  have  been 
fifteen  years  in  the  bowel. 

In  all  these  and  like  cases  it  must  be  a  matter  of  ques- 
tion if  the  evidence  upon  which  the  assumption  is  based 
that  the  stone  entered  the  bowel  at  a  certain  time  is  quite 
to  be  depended  upon. 

Oni^et. — The  onset  is  usually  abrupt,  but  the  degree  of 
acuteness  of  the  symptoms  is  subject  to  no  little  variation. 

Pain. — The  pain  is  severe,  and  of  the  nature  of  colic. 
It  is  continuous  with  marked  exacerbations.  On  the  whole 
it  is  not  so  severe  as  the  pain  which  accompanies  strangu- 
lation by  a  band.  Very  often  the  initial  pain  is  compared 
to  that  of  hepatic  colic. 

Vomiting. — In  these  cases  vomiting  is  an  early  and 
conspicuous  symptom.  It  will  depend  somewhat  upon  the 
position  of  the  calculus  in  the  intestine.  The  nearer  the 
obstruction  to  the  stomach  the  more  marked  is  the  vomit- 
ing, and  the  less  marked,  or  the  longer  delaj^ed,  are  the 
evidences  of  interference  with  the  action  of  the  bowels. 
In  some  cases  of  impaction  in  the  lower  duodenum,  or 
upper  jejunum,  the  vomiting  has  been  very  severe.  Indeed, 
I  know  of  no  form  of  intestinal  obstruction  in  which  the 
vomiting  is  more  incessant,  more  obstinate,  and  more 
copious  than  it  is  in  cases  in  which  the  upper  jejunum 
is  blocked  by  a  gall  stone.  In  a  case  of  Dr.  Pye  Smith's, 
the  gall  stone  was  in  the  upper  part  of  the  jejunum.  The 
vomiting  was  so  profuse  that  no  less  than  one  gallon 
and  a  quarter  of  bilious  fluid  Avas  ejected  in  forty-eight 
hours.  The  patient  died  on  the  sixth  day  after  the  com- 
mencement of  the  symptoms. 

The  vomited  matter  is  apt  soon  to  assume  an  offensive 
odour,  which  is  called  by  some  "intestinal"  and  by  others 
"  feculent."  Schiiller  says  that  the  vomited  matter  was 
stercoraceous  seventy-seven  times  in  120  cases.  Vomiting 
which  may  be  properly  called  stercoraceous  may  occur 
when  the  stone  has  blocked  the  jejunum,  and  this  character 
of  the  ejected  matters  is  pronounced  when  the  stone  has 
engaged  the  lower  ileum. 

Constipation. — In  the  acute  cases  constipation  is,  as  a 
rule,  absolute.  In  subacute  cases  a  more  or  less  free 
action  of  the  bowels  may  be  obtained  after  the  onset  of 
the  symptoms,  and  this  is  especially  marked  in  cases  in 
Avhich  the  stone  has  lodged  m  the  upper  parts  of  the 
small  intestine. 


SYMPTmfS.  3G7 

Constitutional  Sym.ptom.^. — These  are  those  of  acute 
obstruction,  much  modified  according  to  the  abruptness 
and  severity  of  the  attack.  On  the  whole  they  are  much 
less  intense  than  the  general  symptoms  which  attend  acute 
strangulation  of  the  bowel. 

I  have  met  with  no  case  in  which  either  strangury 
or  tenesmus  Avas  a  symptom  and  none  in  which  blood 
was  passed  per  anum. 

In  one  instance,  where  death  followed  in  five  days,  the 
patient,  a  woman  of  sixty-nine,  was  seized  with  violent 
cramps  and  ultimately  died  comatose. 

The  Condition  of  tJte  Abdomen. — This  calls  for  no 
especial  description.  The  degree  of  meteorism  is  usually 
quite  slight,  and  that  symptom  may  indeed  be  wanting, 
'renderness  of  the  abdomen  is  not  met  with  unless  some 
peritonitis  be  present.  It  is  marked  when  an  obstructive 
attack  follows  upon  the  inflammatory  phenomena  which 
may  attend  the  escape  of  a  stone  from  the  gall  bladder 
into  the  bowel. 

In  a  few  cases  the  gall  stone  has  been  felt  through  the 
abdominal  Avail  when  the  patient  was  under  an  ansesthetic. 
Such  was  the  case  in  a  patient  of  Mr.  Eve's,^  in  whom  it 
was  possible  to  feel  a  calculus  lodged  in  the  left  iliac 
fossa. 

Other  Forms  of  Intestinal  Obstruction  due  to  Gall 
Stones. — It  will  be  convenient  to  dispose  of  those  forms  ot 
obstruction  Avhich  are  due  to  gall  stones,  and  to  describe 
in  this  place  such  forms  of  the  trouble  as  are  not  to  be 
ranked  as  acute. 

In  some  cases,  and  perhaps  in  a  large  number  of  cases, 
a  gall  stone  of  considerable  magnitude  may  pass  along  the 
bowel  without  exciting  any  marked  disturbance,  and  may 
indeed  only  cause  trouble  when  it  comes  to  be  evacuated 
at  the  anus.  In  other  instances  the  passage  of  the  calculus 
is  marked  by  attacks  of  colic  from  time  to  time,  by  irregu- 
larity in  the  motions,  by  some  meteorism,  and  by  vomiting. 
The  symptoms  may  be  very  severe  while  they  last,  and 
indicate,  no  doubt,  a  complete  but  temporary  obstruction. 
The  symptoms  after  being  violent  are  not  infrequently 
suddenly  relieved  and  the  patient  passes  in  a  few  moments 
from  a  state  of  intense  suffering  to  a  condition  of  almost 
perfect  ease.  Such  a  transition  is  probably  coincident  with 
the  passage  of  the  concretion  through  the  ileo-ca:!cal  valve 
into  the  colon,  where  it  ceases  to  give  trouble.  The  length 
of  time  that  may  intervene  between  an  attack  of  obstruction 

*  Brit.  Med.  Journ  ,  vol.  i.,  1895,  jj.  195. 


;3G8-  OBSTIirOriON   BY    GALL    STONES. 

and  the  actual  passage  ot  the  stone  may  be  considerable. 
It  may  amount  to  one,  two,  or  even  three  weeks.  "^  In  a 
certain  number  of  the  recorded  cases  there  is  a  history  of 
seveial  attacks  of  obstruction,  which  may  or  may  not  have 
been  brought  about  by  the  same  stone.  Thus  one  patient 
had  two  attacks  only,  the  previous  one  occurring  three 
months  before  death ;  another  had  three  attacks  that 
appeared  eighteen  months,  twelve  months,  and  six  da}'s 
respectively  before  death.  In  another  instance  the  patient 
is  described  as  having  many  attacks  of  a  nature  akin  to 
that  which  proved  fatal  in  the  end. 

In  the  intervals  between  such  attacks  the  bowels  have 
usually  been  irregular  and  the  patient  liable  to  digestive 
disturbances  and  to  sickness ;  or  m  the  absence  of  such 
attacks  there  ma}^  have  been  some  intestinal  irregularities 
simply,  or  certain  symptoms  which  have  probably  been 
associated  with  the  passage  of  the  stone  along  the  intestine. 

As  more  than  one  large  concretion  may  be  in  the  bowel 
at  the  same  time  two  or  more  attacks  of  obstruction 
may  occur  after  the  first  gall  stone  has  been  passed. 
Dr.  Maclagant  describes  two  cases  of  this  kind  and  Mr. 
L'luttonj  another. 

The  symptoms  in  some  examples  are  neither  acute  nor 
chronic.  Such  a  case  is  recorded  by  Dr.  Taylor,  in  which 
the  sj^mptoms  of  obstruction,  after  having  been  marked, 
abated,  and  then  in  a  little  Avhile  became  severe  again. 
In  this  mstance  laparotomy  was  not  performed  until  the 
twenty-seventh  day.  A  gall  stone  four  and  a  half  inches 
in  circumference  and  two  inches  long  Avas  removed  from 
the  lower  ileum.     The  patient  did  well. 

In  another  set  of  cases  the  obstruction  leading  to  death 
has  been  more  chronic.  There  has  been,  perhaps,  absolute 
constipation  for  twenty  days  before  the  individual's  decease, 
and  the  progress  of  the  case  has  been  indolent  and  gradual. 
Such  cases  also  may  or  ma}^  not  have  been  associated  with 
previous  attacks  of  intestinal  disturbance.  In  these  more 
chronic  cases  all  the  symptoms  are  less  marked.  The  pain 
may  be  intermittent,  the  vomiting  is  less  pronounced  and 
is  rarely  stercoraceous,  there  may  be  some  meteorism,  and 
the  coils  of  intestine  may  be  visible  through  the  parietes. 

In  certain  of  these  cases  the  stone  would  appear  to 
cause  but  partial  obstruction,  and  sj^mptoms  are  produced 
which   are   identical   with   those    of  stricture   of    the   small 

*  Diseases  of  the  Gall  Bladder.     By  Mayo  Robson.     London,  1S97. 
t  Clin.  Soc,  Trans.,  Lond..  vol.  xxi.,  p.  87. 
:j:  Ibid.,  p.  79. 


SY^[PTO^rs.  3r,9 

intestine.  Tliat  is  to  sa)'.  there  are  attacks  from  time  to 
time  of  paroxysmal  pain,  some  vomiting  that  rarely  becomes 
stercoraceous  until  quite  the  end  of  the  case,  and  constipation 
Avhieh  may  not  become  absolute,  and  which  may  be  relieved 
by  aperients  and  enemata.  The  coils  of  intestine  also  will 
be  visible  if  the  patient  be  thin.  The  symptoms  will  often 
be  agg-ravated  by  food  and,  indeed,  the  whole  aspect  of  the 
case  closely  resembles  that  of  a  case  of  stricture.  Such  cases 
are  apt  to  end  by  an  acute  attack,  the  pai-tial  obstruction 
becoming  complete. 

Apropos  of  partial  obstruction,  it  should  be  noted  that 
an  impacted  calculus  may  in  time  push  out  a  diverticulum 
from  the  intestinal  wall  and  become  encysted  without  offering 
a  great  obstacle  to  the  passage  of  intestinal  matters.  This 
is  said  to  occur  most  frequently  in  the  duodenum^  although 
it  has  been  also  met  with  in  the  ileum. 

So  far  as  the  duodenum  is  concerned,  it  is  probable 
that  the  diverticula  are  in  most  cases  not  formed  in  the 
manner  described,  but  are  really  instances  of  gall  stones 
which  have  become  encysted  on  their  way  into  the  duo- 
denum, having  escaped  from  the  gall  bladder  by  ulceration. 

It  may  here  be  convenient  to  note  two  or  three 
anomalous  cases  which  possess  some  interest. 

It  would  appear  that  in  some  circumstances  the 
obstruction  of  the  intestine  is  much  assisted  by  an  abrupt 
bending  of  the  bowel  at  the  point  of  impaction  of  the 
stone.  Such  bending  may  at  least  render  a  partial  occlusion 
a  complete  one. 

Thus,  in  the  case  from  which  Fig.  113  was  taken,  the  gut 
was  not  only  blocked  by  a  large  gall  stone,  but  the  intestine 
Avas  acutely  bent  upon  itself  and  tixed  in  that  position  by 
adhesion  of  its  peritoneal  surfaces."^  In  another  instance, 
where  such  a  bend  had  developed,  the  calculus  was  at 
the  extreme  angle  of  the  bend,  and  there  is  little  doubt 
but  that  the  altered  contour  ot  the  bowel  was  the  cause  of 
the  complete  obstruction  that  existed. t 

In  one  remarkable  case  the  pressure  of  the  stone  had 
produced  gangrene  of  the  gut  in  two  places.  The  calculus 
was  found  in  the  ileum  and  was  covered  b}'  a  gangrenous 
piece  of  intestine.  Higher  up  in  the  ileum  was  another 
patch  of  gangrene  one  inch  square.  At  this  point  fatal  per- 
foration had  occurred.  The  calculus  had  a  circumference  of 
three  inches,  and  the  patient,  a  woman  of  sixty-eight,  had 

*  Middlesex    Hosp.    Museum,   No.    viii.,    57.      See  also    Path.  Soc.   Trans, 
vol.  viii.,  p.  231. 

t-  Xen-  Fori;  Meil.  Jonrn.,  1882,  p.  17. 
Y 


370 


OBSTRUCTION  BY    GALL    STOXES. 


had  more  or  less  severe  attacks  of  intestinal  obstruction  for 
the  six  weeks  that  preceded  her  death. "^ 

In  a  case  placed  on 
record  by  M.  Cuffer  the 
patient  died  of  an  obstruc- 
tion situated  in  the  hepatic 
flexure  of  the  colon.  The 
caicum  was  enormously  dis- 
tended, and  had  become 
perforated.  The  hepatic 
tiexure  was  adherent  to  the 
under  surface  of  the  liver 
by  many  adhesions,  and 
among  these  adhesions  was 
a  gall  stone,  the  size  of  a 
bean.  The  bile  ducts  were 
in  a  normal  condition,  but 
the  gall  bladder  had  been 
destroyed.  The  obstruction 
was  due  to  a  narrowing  ot 
the  colon  from  contraction 
of  the  adhesions.  In  this 
case  it  is  probable  that  this 
calculus  had  set  up  inflam- 
mation in  the  gall  bladder, 
that  that  structure  had  in 
consequence  become  ad- 
herent to  the  colon,  and 
that  the  stone,  had  the  case 
been  a  little  more  favour- 
able, Avould  have  been  dis- 
charged into  the  Jarge 
intestine,  and  so  have 
escaped.! 

In  a  case  of  chronic 
obstruction,  where  the 
diagnosis  rested  between 
cancer  and  impacted  gall 
stone,  a  long  needle  was 
repeatedly  thrust  into  the 
abdomen  at  various  points 
in  the  hope  of  striking  the  stone  should  one  exist.  The 
SLone  was  at  last  struck  at  a  depth  from  the  surface 
of    four     and     three-cjuarters    inches.       No     inconvenience 

*  Path.  Soc.  Trans.,  vol.  ix.,  p.  20.3  ;  Dr.  Scott  Allison. 
f  Bull,  de  la  Soc.  Anat.,  1875,  p.  176. 


Fig.   113. — Gall  Stone  impacied  in  tne 

Ileum. 

A  section  has  been  made  of  the  gall  stone. 


SY^^^TO^^s.  '.m 

followed  upon  the  use  of  this  very  undesirable  means  of 
diagnosis.^ 

In  another  instance  Dr.  George  Harleyt  struck  an  im- 
pacted calculus  in  the  bile  duct  by  means  of  a  slender 
trochar  which  had  been  introduced  through  the  parietes  to  a 
distance  of  six  inches.  The  patient  died  twenty-seven  days 
after  the  sounding.  This  and  like  modes  of  examination 
are  to  be  condemned  except  in  very  special  cases.  When  a 
di-tinct  tumour  can  be  felt  or  when  the  site  of  the  obstruc- 
tion is  well  localised,  it  may  possibly  be  justifiable  to  intro- 
duce a  needle  for  the  purpose  of  searching  for  a  gall  stone  or 
other  foreign  substance ;  but  when  these  indications  are 
lacking  I  imagine  that  a  surgeon  is  not  justified  in  thrusting 
a  needle  vaguely  through  the  abdominal  parietes  for  the 
purpose  of  obtaining  aid  in  diagnosis.  Fifty  such  punctures 
may  be  made  before  a  gall  stone  impacted  in  some  parts  of 
the  bowel  may  be  hit. 

Intestinal  Obstruction  by  Foreign  Bodies  and  Entero- 
liths.—  Foreign  Bodies. — ^  There  will  be  a  history  very 
probably  of  the  swallowing  of  a  foreign  body.  The  substance 
may  possibly  be  felt  through  the  parietes  when  the  patient  is 
under  an  ansesthetic,  or  made  evident,  if  it  be  of  suitable 
composition,  by  means  of  the  Rontgen  rays. 

As  to  the  troubles  induced  in  the  bowel  by  foreign  bodies 
there  is  little  to  add  to  what  has  been  already  said  on  p.  185. 

If  the  foreign  substance  block  up  the  bowel,  then  the 
symptoms  produced  are  exactly  like  those  produced  by  a 
gall  stone  and  such  variations  in  the  symptoms  as  may 
depend  upon  gall  stone  may  be  in  like  manner  brought 
about  by  a  foreign  body. 

The  impacted  foreign  substance  may  induce  ulceration  of 
the  gut  and  lead  to  symptoms  of  enteritis. 

Ihe  ulceration  may  in  turn  lead  to  perforation,  to  acute  peri- 
tonitis, to  localised  peritonitis,  or  to  a  circumscribed  abscess. 

Nichollsj  reports  a  case  in  which  a  fatal  peritonitis  was 
due  to  the  perforation  of  the  ileum  by  a  crown,  of  a  species 
of  spear  grass,  which  had  evidently  been  swallowed. 

When  a  localised  abscess  has  formed  it  may  make  its 
way  to  the  surface  and  the  foreign  body  be  discharged  or 
discovered  by  the  surgeon  Avho  evacuates  the  pus  (see  Fig.  77). 

Such  an  example  is  reported  by  Dr.  Maylard,§  a  fish-bone 
having  been  discovered  in  the  abscess. 

*  Med.  Eccord  of  New  York  ;  LU".  James  Whitakcr,  1882. 

t  Paper  read  before  Roval  jMed.-Chir.  8oc.  ;  Lancet,  May  17,  1884. 

X  Brit.  Med.  Journ.,  vol.  i.,  1894,  p.  1242. 

§  Trans,  Path,  and  Clin.  Soc,  Glasgow,  1885,  p.  197. 


372  OBSTRUCTION   BY   ENTEROLITHS. 

The  localised  abscess  may  burst  into  some  hollow  visciis, 
and  the  foreign  body  be  discharged  through  that  viscus. 
This  matter  is  treated  upon  on  page  189. 

Enteroliths. — As  to  the  symptoms  produced  by  enteroliths, 
it  may  be  at  first  said  that  they  vary  greatly  and  depend  a 
good  deal  upon  the  situation  of  the  mass  in  the  intestine. 
They  very  rarely  cause  sudden  occlu&ion  of  the  bowel.  In 
Dr.  Down's  case  of  cocoa-nut  fibre  "stone  "  (see  page  197)  the 
patient,  an  idiot  boy  aged  sixteen,  died  of  acute  obstruction 
which  lasted  for  fifteen  daj^s.  In  this  instance  the  mass  had 
probably  been  formed  in  the  stomach,  and  passing  into  the 
bowel  had  occluded  it.  In  other  cases  also  of  sudden  occlu- 
sion the  calculi  have  been  formed  in  diverticula  of  the  small 
intestine  and  have  then  made  their  way  into  the  bowel  and 
suddenl}^  occluded  it. 

Apart  from  rare  cases  such  as  these  the  symptoms  of 
intestinal  stone  are  distinctly  chronic.  In  some  instances 
there  is  a  history  of  long  continued  digestive  disturbances, 
with  occasional  attacks  of  pain  and  sickness,  and  with 
generally  some  amount  of  constipation.  The  patients  indeed 
present  the  symptoms  of  a  persisting,  incomplete,  and  inert 
obstruction  in  the  intestine.  They  are  apt  to  become 
emaciated  and  hypochondriacal.  Symptoms  such  as  these 
may  continue  for  years.  In  Schroeder's  case,  described  on 
page  197,  the  patient,  a  man  of  fifty-three,  had  suffered  for 
twenty-three  3"ears  from  agonising  attacks  of  abdominal  colic, 
obstinate  constipation,  hEemorrhoids,  meteorism,  cardiac  pal- 
pitation, and  headache.  Mucus  was  passed  from  the  rectum. 
The  enterolith  was  passed  in  due  course,  and  then  all  the 
symptoms  gradually  subsided.  In  Mr.  P.  H.  Watson's  case, 
mentioned  on  page  195,  the  patient,  a  man  over  fifty,  had  had 
evidences  of  abdominal  trouble  for  no  less  than  twenty  years  : 
and  in  other  instances  the  symptoms  have  lasted  for  four,  i'or 
six,  and  for  seven  years  before  the  evacuation  of  the  stono. 
The  mass  also  is  not  infrequently  to  be  felt.  In  l^Ii'.  Watson's 
remarkable  case  a  large  mass  was  felt  in  the  right  hypo- 
chondrium  some  years  before  the  enterolith  was  evacuated. 
The  mass  gradually  moved  towards  the  left  hypochondriuuL 
and  then  disappeared.  Its  disappearance  was  immediately 
iollowed  by  evidences  of  a  foreign  substance  in  the  rectum. 
In  Dr.  Down's  case  also  the  mass  of  fibre  could  be  felt 
through  the  parietes.  It  is  needless  to  say  that  many  con- 
cretions have  been  detected  by  rectal  examination  when 
they  occupy  the  terminal  part  of  the  bowel. 

In  other  cases,  the  calculus  when  lodged  in  the  cfecum  may 
cause  perityphlitis  and  finally  lead  to  perforation  and  death. 


373 


CHAPTER    YI. 

THE  COURSE  AND   PROGNOSIS  IN    ACUTE    INTESTINAL 
OBSTRUCTION. 

1.  Straxgulatiox  by  Bands  or  through  Apertures. — 
The  course  in  this  variety  of  intestinal  obstruction  is  ver}^ 
rapid  and  the  prognosis  very  bad. 

The  average  duration  of  a  case  is  about  live  days.  The 
extremes  are  eight  hours  and  twenty  days.  It  may  be  sate 
to  say  that  every  case  unless  relieved  ends  in  death.  The 
prognosis  is  more  serious  even  than  is  the  prognosis  in 
strangulated  hernia,  owing  to  the  fact  that  the  parts  engaged 
are  well  within  the  abdominal  cavity. 

The  issues  of  the  case  are  of  course  affected  by  the 
ordinary  circumstances  which  govern  all  prognosis,  such  as 
the  age  and  health  of  the  patient,  the  condition  of  the  bowel 
at  the  time  of  strangulation,  and  other  obvious  circumstances. 

The  duration  of  any  given  case  depends,  I  think,  neither 
so  much  upon  the  age  of  the  patient  nor  the  situation  of  the 
obstruction  in  the  lesser  bowel,  as  upon  the  tightness  of  the 
strangulation  and  the  amount  of  bowel  involved.  The  most 
rapidly  fatal  cases  are  those  in  which  a  considerable  quantity 
of  intestine  has  been  severely  strangulated.  The  two  con- 
ditions must  be  combined  ;  for  in  some  of  the  least  acute 
cases  large  coils  have  been  found  to  have  been  involved,  but 
only  moderately  compressed.  As  a  solitary  factor,  the  rigour 
of  the  incarceration  is  the  most  important  in  bringing  about 
a  rapidly  fatal  termination.  The  larger  the  coil  so  involved 
the  more  severe  the  manifestations. 

A  sudden  onset  of  symptoms  need  not  mean  a  very 
rapid  course.  Some  of  the  examples  of  abrupt  onset  show 
a  poriod  of  ten  to  thirteen  days  before  death  ensued.  As 
a  rule,  however,  the  more  gradual  the  development  of  the 
symptoms  the  longer  is  the  probable  duration  of  the  case. 


374  STRANGULATION   BY   BANDS. 

There  is  a  case  reported  by  Dr.  Peacock  that  is,  I  should 
imagine,  unique.  It  concerns  a  man,  aged  sixty-five,  Avho 
died  collapsed,  and  in  Avhose  abdomen  a  small  knuckle  of 
the  ileum  was  found  strangulated  by  a  band.  The  involved 
gut  was  gangrenous.  The  patient  is  said  to  have  been  ill 
six  days  with  constipation,  but  to  have  worked  up  to  the 
morning  of  his  death. 

Since  in  snaring  by  loops  or  knots  larger  coils  are,  on 
an  average,  involved  than  in  the  case  of  strangulation  under 
a  band,  it  follows  that  the  progress  of  the  malady  is  more 
rapid  in  the  former  variety  of  strangulation  than  in  the  latter. 
In  the  former  class  of  case,  moreover,  the  incarceration  is 
usually  more  complete  and  more  rigorous.  Thus  the  average 
duration  until  death,  in  a  case  of  strangulation  under  a 
band  or  through  an  aperture,  is  six  days.  The  average 
duration  in  a  case  of  snaring,  whether  by  a  false  ligament 
or  by  a  diverticle,  is  four  days. 

Some  of  the  most  acute  cases  led  to  death  in  ten, 
seventeen,  and  tAventy-four  hours,  while  in  the  least  severe 
instances  life  was  prolonged  to  the  thirteenth,  fourteenth, 
and  fifteenth  day.  Le  Moyne,  for  example,  mentions  two 
cases,  both  in  young  soldiers  in  perfect  health,  in  which 
death  took  place  in  ten  hours  and  eighteen  hours  respectively. 
In  the  one  case  the  ileum  was  engaged  in  a  slit  in  the 
mesentery,  and  in  the  other  the  ileum  was  strangulated 
beneath  a  diverticular  ligament. 

Opium,  if  given  in  large  doses,  has,  as  already  stated,  a 
considerable  ettect  upon  the  progress  of  any  given  case. 
Under  its  use  the  pain  and  vomiting  have  greatly  diminished, 
the  pulse  has  improved,  the  temperature  has  risen,  and  the 
patient  has  been  placed  apparently  in  a  much  more  favour- 
able condition. 

The  onset  of  stercoraceous  vomiting  is  a  matter  of 
moment.  If  a  large  body  of  cases  of  acute  obstruction  of 
the  present  variety  be  examined,  it  will  be  noticed  that 
on  an  average  life  is  only  prolonged  three  days  after  the 
appearance  of  stercoraceous  (or  as  it  is  often  called 
fsecuient)  vomiting. 

The  mode  in  which  death  takes  place  varies. 

Some  patients  die  of  collapse,  others  of  perforative  peri- 
tonitis, while  the  majority  succumb  to  septicaemia.  In 
this  septictemia  the  poison  is  derived  from  the  putrid  matter 
within  the  patient's  own  intestine,  and  in  the  production 
of  this  septic  material  the  bacterium  coli  commune,  no 
doubt,  plays  a  prominent  part.  In  one  instance  or  so  the 
death  has  deen  ascribed  to  heart  failure,  to  mere  exhaustion, 


COURSE   AND    PROGNOSIS.  375 

to  the  inhalation  of  vomited  matters,  and  to  suppurative 
changes  about  the  gut  in  cases  which  are  not  markedly 
acute. 

Peritonitis  of  a  pronounced  type  is  not  very  commonly 
found  in  this  form  of  strangulation  of  the  bowel.  It  is 
met  with  in  a  little  more  than  one  half  of  the  cases.  The 
period  of  its  onset  and  the  conditions  under  which  it  appears 
vary  greatly.  It  has  been  recorded  as  present  in  a  patient 
who  died  in  seventeen  hours  after  the  commencement  of 
the  obstructive  attack,  while  it  has  been  found  to  be  entirely 
absent  in  another  case  where  the  individual  lived  fourteen 
days.  The  average  time  for  its  appearance  is  about  the 
fifth  day. 

Perforation  of  the  bowel  above  the  seat  of  obstruction 
is  quite  uncommon,  and  would  not  appear  to  occur  in  more 
than  10  or  12  per  cent,  of  all  the  cases.  It  has  caused 
death  as  early  as  the  fifth  day. 

In  speculating  as  to  the  possibility  of  spontaneous 
recovery  in  cases  of  this  form  of  strangulation  of  the  bowel, 
one  cannot  fail  to  note  that  patients  who  have  ultimately 
died  of  acute  obstruction  have  sometimes  had  previous 
"  attacks "  which,  so  long  as  they  lasted,  were  as  severe  as 
the  linal  one.  It  would  not  be  unreasonable  to  assume 
that  these  previous  disturbances  were,  in  some  cases  at 
least,  brought  about  by  the  same  mechanism  that  caused  at 
last  the  fatal  attack.  If  so,  they  may  prove  to  be  instances 
of  spontaneous  relief  of  an  acute  obstruction.  Among  older 
records  there  is  no  doubt  but  that  not  a  few  of  these  cases 
of  recovery  from  acute  obstruction  are  really  cases  of  recovery 
from  recurrent  peritj^phlitis. 

Then,  again,  one  isolated  case  or  so  has  been  recorded 
where  patients  were  attacked  with  symptoms  of  intestinal 
incarceration  which  could  not  be  diagnosed  from  like  attacks 
known  to  be  due  to  "  bands."  These  patients,  after  being 
almost  in  articido  mortis,  after  vomiting  stercoraceous  matter 
for  days,  after  presenting  the  phenomena  of  absolute  obstruc- 
tion, have  at  last  recovered.  So  far  as  I  am  aware,  no 
autopsy  at  a  subsequent  date  has  made  clear  the  nature  of 
such  miraculous  cases,  and  therefore  that  they  may  have 
been  cases  ot  strangulation  by  bands  must  be  a  matter  of 
pure  conjecture. 

In  the  face  of  instances  like  these  it  is  well  to  observe 
what  light  the  post-mortem  examination  of  fatal  cases  can 
throw  upon  this  question  of  spontaneous  relief.  There  is 
not  the  least  reason  for  supposing  that  the  bowel,  when  it 
has  been  strangulated  for  a  certain  length  of  time,  has  the 


376  STRANGULATION   BY   BANDS. 

least  power  of  removing  itself"  from  the  constricting  agent. 
What  we  know  of  strangulated  hernia  would  support  this 
impression.  There  is  a  circumstance,  however,  in  which 
spontaneous  reduction  may  occur  in  cases  of  incarceration 
of  recent  standing.  It  is  when  a  loop  of  gut  has  passed 
beneath  a  band  and  has  then  become  so  twisted  as  to 
have  its  lumen  closed.  In  such  a  case  sudden  and  severe 
symptoms  may  appear,  and  yet  the  band  without  the  volvulus 
may  not  suffice  to  strangulate  the  gut.  As  the  muscular 
vigour  of  the  gut  becomes  impaired,  or  is  rendered  feebler 
by  the  action  of  opium,  it  is  possible  to  conceive  that  the 
volvulus  may  untwist  and  the  coil  escape  from  the  band 
that  never  held  it  other  than  slightly.  This  may  be  the 
explanation  of  some  of  the  "  previous  attacks "  noted  in 
cases  of  fatal  strangulation. 

When  the  strangulation  is  well  advanced  recovery  bv 
this  means  must  be  practically  impossible.  I  have  alluded 
to  two  cases  where  the  involved  gut  was  found  to  be 
partially  reduced  after  death ;  but  in  these  cases  the 
reduction  had  been  effected  by  the  sudden  relief  to 
distension  caused  by  a  perforation.  Ihe  very  cause  that 
brought  the  relief  but  served  to  hasten  the  appearance  of 
death. 

One  possible  factor  in  spontaneous  recovery  may  be  the 
giving  way,  from  gangrene,  of  the  constricting  band.  Post- 
mortem examinations  afford  some  support  to  any  theory 
based  upon  this  circumstance.  Many  of  the  bands  that 
cause  obstruction  are  very  thin,  and  have  but  a  poor  blood 
supply.  They  must  be  greatly  compressed  when  they  pro- 
duce strangulation,  and  yet  experience  shows  that  they 
usually  outlive  the  too  vascular  bowel.  There  are,  however, 
cases  where  the  patient  seems  to  have  been  very  near  a 
prospect  of  spontaneous  recovery  when  death  occurred. 
Among  these  are  the  following :  In  one  case  of  laparotomy 
performed  on  the  third  day  of  the  acuter  symptoms,  the 
band  on  being  handled  was  found  to  be  so  slender  that  it 
broke  as  it  was  being  lifted  up.'^  In  two  other  cases  a 
diverticulum  that  had  caused  obstruction  was  found  to  be 
so  softened  that  it  was  partly  torn  away  from  its  point  of 
origin,  t  In  another  case  of  laparatomy,  which  ended  in 
cure,  the  diverticulum  was  more  livid  than  the  gut  that 
it    was   compressing  j  ;    and    lastly,   Dr.    Servier   quotes    an 

*  IJull.  eh  Mem.  de  la  8oc.  de  Chir.  de  Paris,  1879,  p.  b6i. 
t  ]>i'.  Hilton  Fagge,  loc.  cdt. ;    and  Dr.  Wilks,  Path.  Soc.  Trans.,  vol.  xvi., 
p.  12G. 

J  liull.  ct  IMern.  de  la  Soc.  de  Chir.  de  Paris,  1881,  p.  210. 


COURSE   AXD    FROGXOSIS.  377 

instance  where  the  constricthio-   band   was  sfano^renoiis   and 

O  O  CD 

on  the  point  of  rupturing.* 

In  connection  with  the  question  of  diverticula  becoming 
gangrenous,  it  must  be  borne  in  mind  that  such  an  event 
may,  instead  of  leading  to  cure,  lead  to  death  by  perforation 
should  the  gangrenous  part  of  the  process  be  pervious. 
Indeed,  the  tearing  away  of  the  diverticle  has  caused  fatal 
peritonitis,  and  Cazin  notes  a  case  where,  through  the  rent  so 
formed,  some  metallic  mercury  which  had  been  administered 
found  its  way  into  the  peritoneal  cavity. 

A  specimen  in  St.  Thomas's  Hospital  Museum t  shows 
another  possible  means  of  escape,  although  a  very  remote 
one.  The  specimen  consists  of  a  part  of  the  small  intestine 
of  a  dog,  around  a  knuckle  of  Avhich  Mr.  Travers  had,  during 
life,  firml}^  tied  a  ligature.  The  animal  died  on  the  third 
day.  The  ligatured  part  had  separated,  and  was  found  in 
a  kind  of  cyst  formed  by  lymph  from  the  peritoneum.  Into 
this  cyst  the  two  ends  of  the  bowel  opened  so  that  the 
integrity  of  the  tube  was  practicall}^  restored.  It  is  conceiv- 
able that  such  a  circumstance  may  occur  in  a  young  human 
subject  when  only  a  small  knuckle  of  gut  or  a  part  of  the 
circumference  of  the  gut  is  very  tightly  strangulated. 

It  is  not  impossible  that  in  a  favourable  case  the  canal 
of  the  intestine  may  be  completed  after  obstruction  by  the 
formation  of  a  "fistula  bimucosa"  such  as  has  been  formed 
in  some  cases  of  strangulated  hernia.  The  relief  in  such 
an  instance  would  be  identical  to  that  obtained  by  the 
operation  of  lateral  anastomosis. 

From  the  above  speculations  the  conclusion  may  safely 
be  drawn  that  while  spontaneous  relief  in  acute  obstruction 
may  not  be  impossible  it  must  at  least  be  excessively  rare. 

2.  Volvulus  of  the  Sigmoid  Flexure. — Volvulus  of  the 
sigmoid  flexure  is,  so  far  as  is  known,  invariably  fatal  unless 
relieved  b}^  surgical  interference.  The  case  progresses  from 
bad  to  worse,  as  a  rule  uninterruptedly,  but  sometimes 
with  remissions  in  the  severity  of  the  symptoms. 

The  average  duration  of  the  attack  in  the  series  of  cases 
I  have  collected  was  six  days.  The  longest  period  during 
which  the  patient  lived  was  twenty  days,  X  the  shortest 
sixty-four  hours.  §  Nothnagel  alludes  to  instances  of  death 
in  tweh'e  and    t went}"- four   hours,  but  gives  no  particulars. 

*  De  rOcclusion  Intestinale,  p.  42.     Liege,  1871. 
t  No.  Q  7. 

j  Contrib.    a    I'Etude    do    rOcclusion     iiitestinale,     bv     Dr.     Le    Movne. 
Paris,  1878. 

§  A  case  by  Melchiori  (^uoled  by  Dr.  Licbaut  in  his  monograph. 


378  VOLVULUS    OF    THE    SIGMOID    FLEXURE. 

The  only  circumstance  that  appears  to  influence  the  rapidity 
of  the  case  is  the  severity  of  the  twist.  It  is  unaffected 
by  the  age  of  the  patient  and  by  the  preceding  synjptoins. 

The  cases  that  set  in  abruptly  usually  display  the  most 
rapid  course.  In  the  patient,  however,  who  lived  twenty 
days  the  onset  was  sudden.  In  another  case,  on  the  other 
hand,  where  the  onset  was  gradual  the  patient  died  in  three 
days. 

The  causes  of  death  in  the  more  rapid  cases  are 
collapse,  interference  with  the  thoracic  organs  by  the  enor- 
mously distended  bowel,  peritonitis,  and  above  all  intestinal 
septicaemia.  In  the  more  chronic  cases  death  is  ascribed 
to  peritonitis,  septicaemia,  and  exhaustion.  The  two  patients 
who  lived  for  the  shortest  periods  (sixty-four  and  sixty- 
eight  hours  respectively)  are  both  said  to  have  died  as- 
phyxiated. In  cases  which  have  survived  for  a  longer  time 
the  fatal  issue  is  often  somewhat  sudden;  and  here  it  may 
be  surmised  that  the  greatly  distended  flexure  has  interfered 
with  the  action  of  the  heart  or  lungs  bj^  actual  pressure 
through  the  diaphragm.  Before  death  the  patient  has,  in 
more  than  one  instance,  complained  of  great  pain  in  the 
chest  and  of  trouble  in  the  cardiac  region.''^  An  instance 
of  sudden  death  reported  by  M.  Potain  may  here  be  noticed. 
A  man,  aged  thirty-three,  who  had  been  long  troubled  with 
constipation,  was  admitted  into  hospital  with  simple  obstruc- 
tion. His  bowels  had  not  been  relieved  for  eight  days.  An 
enema  merely  brought  away  a  few  scybala.  His  abdomen 
Avas  swollen,  but  it  was  neither  tender  nor  painful.  He 
had  not  vomited.  He  had  no  dyspnoea.  The  morning  after 
his  admission  he  was  found  dead  in  his  bed.  His  decease 
had  not  been  observed  by  the  patients  lying  on  either  side 
of  him  in  the  ward.  The  autopsy  revealed  a  double  twist 
of  the  sigmoid  flexure,  but  Avith  no  peritonitis.  The  gut 
was   fully   distended.      All  the  other   viscera   were  healthy. 

Two  patients  out  of  twenty  recorded  cases  died  of  per- 
foration of  the  bowel  above  the  volvulus. 

There  is  no  evidence  to  show  that  a  volvulus  of  this  part 
can  ever  spontaneously  relieve  itself  when  once  the  twist  is 
well  established.  The  reported  case  of  a  patient  who  had 
had  previous  attacks  of  pain  with  obstruction,  and  who 
on  each  occasion  but  the  last  obtained  innnediate  relief 
by  assuming  a  peculiar  posture,  suggests  a  possible  means  ot 
spontaneous  relief  in  slight  and  recent  cases.  When  the  gut 
has  become  twisted  it  is  conceivable  that  a  change  in  the 
patient's  position,    or   some  shifting   in    the  position  of   the 

*  8ee  for  example  a  case  by  jNIr.  Gay  ;  Path.  Soc.  Trans.,  vol.  x.,  p.  153. 


COURSE   AND    PROGNOSIS.  379 

irregularly  placed  contents  of  the  coil,  or  some  unusual 
movement  of  the  bowel  itself,  may  unwind  the  volvulus. 
When,  however,  the  occlusion  has  lasted  long  enough  to 
allow  the  bowel  to  become  distended  the  volvulus  is  almost 
certain  to  be  rendered  permanent. 

I  have  in  a  previous  section  (page  85)  alluded  to  the 
fact  that  when  the  lower  part  of  the  sigmoid  flexure,  or  the 
upper  part  of  the  rectum,  becomes  suddenly  occluded  by  the 
process  known  as  kinking,  symptoms  may  be  induced  which 
precisely  resemble  those  of  the  present  form  of  obstruction. 
I  have  mentioned  an  example  of  this  where  all  the  symptoms 
closely  resembled  those  of  volvulus.  The  patient  was  middle- 
aged  ;  she  had  been  troubled  with  constipation  for  some 
time ;  the  onset  of  the  attack  was  sudden  ;  swelling  of  the 
abdomen  was  rapid  and  marked ;  the  pain  was  constant, 
with  exacerbations ;  the  vomiting  was  not  severe  and  not 
stercoraceous ;  peritonitis  was  developing.  The  rectum  had 
been  closed  by  kinking,  and  the  sigmoid  flexure  filled  a  great 
part  of  the  abdomen  (p^ge  86). 

The  prognosis  of  the  other  varieties  of  volvulus  is  con- 
sidered in  the  section  which  deals  with  the  clinical  I'eatures 
of  those  uncommon  varieties  (see  pages  344  and  345) 

3.  Intussusception. — It  will  be  more  convenient  to  con- 
sider in  this  place  the  future  of  all  types  of  intussusception, 
as  it  is  difficult  in  dealing  with  the  course  and  prognosis  of 
the  affection  to  separate  the  acute  cases  from  the  chronic. 
A  brief  reference  to  the  course  and  ending  of  the  chronic 
cases  is  given  on  pages  418  and  433,  but  the  main  features 
in  the  prognosis  will  be  considered  in  this  place. 

Compared  Avith  the  acute  cases  the  chronic  forms  are 
comparatively  unimportant,  and  they  play  no  very  con- 
spicuous part  in  the  general  circumstances  of  intussuscep- 
tion. 

Kafinesque  divided  intussusception  into  four  clinical 
forms:  (1)  The  ultra-acute,  when  the  patient  dies  within  the 
first  twenty-four  hours.  (2)  The  acute,  when  the  duration 
of  the  disease  extends  between  two  and  seven  days.  (3) 
The  subacute,  when  it  extends  between  seven  and  thirty 
days.  (4)  The  chronic,  when  the  malady  lasts  beyond  the 
period  of  one  month. 

No  definite  line,  of  course,  can  be  drawn  to  separate 
these  various  iorms  from  one  another.  The  division  is 
arbitrary,  but  is,  from  a  clinical  point  of  view,  convenient. 

The  relative  frequency  of  these  different  forms,  as  ascer- 
tained i'rom  an  examination  of  the  fatal  cases,  may  be 
expressed  as  follows : 


3S0  IXTUSS  USGEPTION. 

Acute .48  per  cent. 

Subacute 34         „ 

Chronic 18         „ 

100 

The  ultra-acute  form  is  extremely  rare.  Leichtenstern 
met  with  only  five  examples  of  it  among  269  fatal  cases. 

The  site  of  the  invagination  greatly  influences  its  course. 
Thus  the  enteric  and  ileo-colic  forms  are  usually  acute  or 
subacute,  the  great  majority  of  the  examples  of  both  these 
varieties  terminating  within  the  first  fourteen  days  of  the 
attack.  Colic  and  rectal  invaginations  are  more  often 
chronic  or  subacute  than  acute,  lleo-csecal  intussusceptions, 
being  the  most  common  form  of  the  malady,  are  met  with 
in  all  the  grades  of  the  affection.  Three-fourths,  however, 
of  the  cases  are  either  subacute  or  chronic.  Sixty  per  cent, 
of  the  examples  of  chronic  invagination  belong  to  the  ileo- 
Ciecal  variety. 

The  age  of  the  patient  also  greatly  influences  the  proj^ress 
of  the  affection.  This  is  well  demonstrated  in  the  subjoined 
analysis  ot  269  fatal  cases  collected  by  Leichtenstern.  It 
shows  that  invagination  in  the  .very  young  has  a  great 
disposition  to  run  an  acute  course.  Four  out  of  live  ultra- 
acute  cases  occurred  in  children  not  over  a  year  old ;  and 
no  less  than  seventy-nine  out  of  129  acute  cases  occurred 
also  in  patients  who  wore  not  more  than  twelve  months 
of  age. 

the  general  mortality  of  intussusception  is  about  70  per 
cent.  Leichtenstern  has  pointed  out  that  the  malady  is 
somewhat  more  i'atal  in  females  than  in  males,  and  gives  the 
following  as  the  results  obtained  from  his  statistics :  Males, 
mortality  68  per  cent.  ;  females,  70  per  cent. 

The  ultra-acute  cases  are  all  fatal,  the  patients  dying  of 
shock  within  a  comparatively  short  time  from  the  commence- 
ment of  the  attack.  In  the  Royal  College  of  Surgeons  is  an 
intussusception  of  the  ileum,  one  inch  long,  from  an  infant 
aged  fifteen  weeks  who  died  in  nine  hours  (specimen 
No.  2701).*  A  very  high  mortality  runs  through  the  acute 
eases,  especially  through  such  as  occur  in  young  children. 

Most  of  the  cases  of  recovery  are  met  with  in  the  subacute 
variety  of  the  malady.  The  mortality  among  distinctly 
chronic  cases  is  again  high.  Out  of  filty-nine  clironic  cases 
collected  by  Rafinesque  there  were  no  less  than  fifty-one  that 
terminated  fatally. 

*  As  a  gi:od  example,  see  Lnnect,  vol.  i.,  1882,  p.  G04.  The  child  lived 
{hirteen  hovus. 


COURSE    AND    PROGNOSTS. 


3^1 


The  extremely  fatal  character  assumed  by  intussiisception 
in  infants  under  one  year  old  is  well  illustrated  in  the  sub- 
joined table. 

In  over  80  per  cent,  of  the  fatal  cases  death  occurred 
before  the  seventh  day.  In  children  that  are  a  little  older 
the  fatal  termination  usually  takes  place  towards  the  end  of 
the  first  week,  or  the  commencement  of  the  second.  In 
adults,  death  usually  takes  place  during  the  course  of  the 
second  and  third  weeks;  many,  however,  dj'ing  after  the 
malady  has  become  chronic. 

According  to  Leichtenstern,  the  deaths  between  the  ages 
of  eleven  and  sixty  years  are  met  with  in  the  different 
anatomical  varieties  in  the  folloAving  proportions  :  The  ileo- 
cecal forms,  71  per  cent.;  enteric,  57"8  per  cent.;  colic, 
70-9  per  cent. 


Time  of  Death. 


The  1st  day  . 

TLe  2nd  day 

The  3r.l  day 

The  4th  to  the  7th  day" 

In  the  2nd  week  . 

In  the  3rd  week   . 

In  the  4th  week   . 

In  the  2nd  and  3rd  months 

In  the  4th  and  5th  months 

In  the  6th  and  7th  months 

In  the  8th  month. 

In  the  9th  month. 

In  the  10th  or  11th  month 

After  1  year. 

After  2  years 


Ages  of  Patiexts. 


4 
18 
2G 
35 
10 
2 
2 

1 

0 
0 
0 
0 
0 
0 


Total 


100 


. 

od 

?5 

?i 

?5 

>^ 

>^ 

f>5 

o 

o 

o 

o 

■>< 

-f 

o 

o 

o 

o 

c 

i?a 

._! 

,—, 

,—1 

0 

0 

'.M 

0 

0 

1 

'      4 

2 

1 

I 

0 

2 

1 

2 

0 

1 

10 

7 

4 

3 

4 

6 

4 

10 

13 

5 

2 

1 

3 

8 

0 

1 

1 

0 

5 

4 

1 

2 

5 

8 

5 

2 

0 

0 

.7 

1 

0 

0 

0 

1 

0 

1 

1 

0 

1 

0 

0 

0 

0 

1 

0 

0 

0 

0 

2 

0 

0 

0 

0 

0 

0 

0 
29 

0 

0 

0 

1 

19 

25 

51 

21 

5 

26 

35 

68 

51 

18 

15 

27 

11 

3 

3 

1 

3 

2 

1 


20    269 


Methods  of  Spontaneous  Cure. — In  a  great  many  in- 
stances intussusceptions  have  been  cured  by  treatment,  some 
have  been  successfully  reduced  after  laparotomy  had  been 
performed,  others  have  been  unfolded  by  means  of  enemata 
and  insufflation  of  air. 

With  these  cases,  however,  we  have  at  present  no  concern, 


382  IN  TITS S  US  CEP  TION. 

and  have  to  deal  only  with  instances  where  the  invagination 
has  cured  itself. 

Cases  of  spontaneous  cure  may  be  divided  into  two  distinct 
categories:  1.  Those  which  occur  in  invaginations  that  are 
still  reducible.  2.  Those  which  occur  in  invaginations  that 
are  quite  irreducible. 

To  the  first  category  belong  instances  of  spontaneous 
reduction.  Of  the  existence  of  this  mode  of  cure  there  can 
be  no  doubt,  although  its  occurrence  must  be  a  matter  of 
some  rarity.  There  are  several  instances  reported  of  fatal 
intussusception  in  which  the  patient  has  had  one  or  more 
previous  attacks  which,  in  all  points  save  duration,  resem- 
bled the  earlier  stages  of  the  fatal  attack.  There  is  every 
reason  to  suppose  that  such  previous  attacks  were  due  to  the 
formation  of  intussusceptions  which  underwent  spontaneous 
reduction. 

I  think,  moreover,  that  some  of  the  cases  of  supposed  cure 
of  invagination  by  large  doses  of  opium,  administered  promptly, 
have  been  instances  of  spontaneous  reduction ;  the  curative 
movement  being  rendered  more  easy  by  the  state  of  nerve 
repose  induced  by  the  sedative. 

There  are  one  or  two  cases  where  patients  have  died  after 
having  presented  many  of  the  symptoms  of  invagination,  and 
where  after  death  nothing  was  found  save  a  piece  of  small 
intestine  shrunken  and  congested.  Such  cases  might  well 
have  been  instances  of  the  spontaneous  reduction  of  an  enteric 
invagination,  although  they  are  described  as  examples  ot 
death  from  "  spasm,"  or  from  paralysis  of  a  pDrtion  of  the 
bowel*  A  case  reported  by  Mr.  Gay  affords  probably  a  little 
more  direct  evidence  concerning  this  matter.  The  patient 
was  a  woman,  aged  thirty-eight,  who  was  admitted  into 
hospital  with  symptoms  of  obstruction.  The  symptoms  had 
appeared  suddenly  ;  there  was  fixed  and  localised  pain,  a  hard 
tumour  to  the  left  of  the  umbilicus,  constipation  and  vomit- 
ing. The  symptoms  in  a  short  while  passed  off'  suddenly. 
The  patient  was  phthisical,  and  died  in  two  days  of 
pulmonary  haemorrhage.  The  autopsy  revealed  a  contraction 
of  a  limited  portion  of  the  ileum,  and  the  gut  presented 
distinct  evidences  of  recent  constriction. 

It  may  be  surmised  that  spontaneous  reduction  can  only 
occur  in  quite  recent  cases,  and  probably  only  in  the  enteric 
form  of  invagination.  A  remarkable  case  recorded  by  Killiet 
would  appear  to  point  to  the  possibility  of  spontaneous  reduc- 

*  See  case  recorded  by  Henrot;  Des  Pseudo-etranglements,  p.  53.  Paris, 
I860.  Also  case  by  Travers  ;  Inquiry  into  the  Process  of  Nature  in  rej airing- 
Injuries  of  the  Intestines,  p.  211,  London,  1812. 


C.OUBSE    AND    rBOGNOSTS.  383 

tion  in  cases  of  some  standing.  Rilliet's  patient  was  a  boy, 
aged  ten,  who  was  taken  on  July  1st  with  abdominal  pains. 
(3n  August  4th  he  vomited;  August  5th  and  6th  were  marked 
by  the  appearance  of  severe  intermittent  attacks  of  colic,  and 
evidences  of  a  painful  tumour  in  the  right  flank.  Black  fetid 
stools  were  passed.  The  attacks  of  pain  were  followed  by 
intervals  of  complete  ease.  By  the  9th  the  tumour  had 
become  softer  and  less  defined.  Diarrhoea  set  in  on  the  10th, 
the  stools  containing  a  little  blood.  The  tumour  gradually 
diminished  and  disappeared  and  the  child  got  well.'^  Rafin- 
esque  reports  in  his  monograph  a  somewhat  similar  case.  In 
both  these  cases  it  would  have  to  be  shown  that  the  obstruc- 
tion was  not  due  to  the  impaction  of  faices  or  undigested  food 
before  they  could  be  accepted  as  intussusceptions. 

The  following  case  reported  by  Nothnagel  is  more  precise. 
The  patient  was  a  healthy  man  of  fifty  who  had  never  had 
any  bowel  troubles.  In  April,  1892,  he  was  quite  suddenly 
attacked  with  violent  colicky  pains  which  radiated  from  the 
right  iliac  region.  These  attacks  of  colic  were  repeated  for 
almost  four  months.  They  came  on  at  intervals  of  one  to 
three  days,  and  lasted  from  twelve  to  twenty-four  hours. 
They  were  accompanied  by  nausea  and  vomiting. 

Gradually  it  was  noticed  that  during  these  attacks  coils  of 
intestine  were  to  be  seen  in  movement  through  the  abdominal 
parietes.  The  bowels  acted  normally  every  day.  The  patient  be- 
came much  emaciated.  He  entered  hospital  in  June,  and  the 
case  was  diagnosed  as  a  new  growth  of  the  intestine.  Operation 
Avas  proposed  but  declined.  Strange  to  sa}'-,  while  in  the  hos- 
pital all  the  patient's  symptoms  vanished  without  treatment 
of  any  kind,  and  in  four  weeks  he  left  the  hospital,  ap23arently 
cured.  He  remained  in  robust  health  for  one  year  and  three 
months.  In  November,  1 893,  his  former  troubles  reappeared, 
and  assumed  precisely  the  same  characters  as  before.  He 
became  greatly  emaciated,  and  was  exhausted  by  the  frequent 
pain,  the  vomiting,  and  the  loss  of  sleep.  The  bowels  continued 
to  act  with  perfect  regularity,  and  were  normal  in  appearance. 
In  April,  1894,  he  came  under  the  care  of  Dr.  Nothnagel. 
A  tumour  Avas  now  discovered,  apparently  in  the  transverse 
colon,  which  had  all  the  characters  of  an  invagination  tumour. 
Hypertrophied  coils  of  small  intestine  could  be  seen  during 
the  attacks  of  colic.  Lapaiotomy  was  performed  and  an 
ileo-csecal  invagination  discovered.  At  the  summit  of  it  was 
a  polypus.  There  was  no  trace  of  peritonitis,  there  Avere 
no  adhesions,  and  the  invagination  Avas  reduced  Avithout  the 
least  difficulty.     The  patient  made  a  good  recovery. 

*  Gazette  des  Hopitaux,  1852. 


381  INTUSSUSCfEPTIOy. 

To  the  second  category  belong  two  kinds  of  cases.  In 
one  a  fsecal  fistula  is  formed  in  the  bowel  above  the  intussus- 
ception. In  the  other,  spontaneous  cure  is  brought  about 
by  ehmination  of  the  invaginated  bowel. 

The  formation  of  a  f cecal  Jistidrt  must  be  extremely  rare. 
I  have  only  been  able  to  find  one  example  of  such  a  mode 
of  relief.  The  case  is  reported  by  Bruchet,  and  concerns  a 
man  of  sixty-seven,  who  for  three  or  four  months  before  his 
death  passed  fsecal  matter  with  his  urine.  The  autopsy 
showed  a  short  intussusception  of  the  colon  into  the  sigmoid 
flexure  with  above  it  a  fistulous  opening  into  the  bladder."^ 
It  will  be  understood  that  should  a  fsecal  fistula  (due  to 
ulceration  above  the  obstruction)  form  and  make  iis  outer 
orifice  in  the  integuments,  an  artilicial  anus  may  be  pro- 
duced which  could  give  permanent  relief. 

Elimination  of  the  invaginated  bowel  by  gangrene  is 
the  only  common  form  of  spontaneous  cure.  The  account  of 
the  pathology  of  the  process  has  already  been  given  (page 
165).  For  statistics  on  the  matter  we  have  again  to  turn  to 
Leichtenstern,  whose  collection  of  cases  is  greatly  in  excess 
of  that  made  by  any  other  author. 

Spontaneous  elimination  (according  to  this  author)  occurs 
in  about  42  per  cent,  of  all  cases.  It  is  a  little  influenced 
apparently  by  sex,  occurring  in  54  per  cent,  of  the  female 
cases  and  in  31  per  cent,  of  the  cases  in  males. 

It  is  greatly  influenced  by  the  position  of  the  intussus- 
ception. 

Thus,  in  the  ileo-cascal  invaginations 

it  occurred  in 20  per  cent,  of  the  cases. 

In  colic 28         „  „ 

In  enteric 61        „  „ 

Still  more  conspicuously  is  spontaneous  elimination  in- 
fluenced by  age,  being  extremely  rare  in  children  under 
two  years  of  age. 

Leichtenstern's  statistics  upon  this  point  yield  the  follow- 
ing results  : 

In  the  first  year  of  age  spontaneous 

elimination  occurred  in   . 
Between  the  2nd  and  5th  year 
„  6th     „      10th   „     , 

„  11th     „      40th    „     , 

„  41st      „      60th   „ 

Above  the  age  of  60  years 

The  period  of  time  in  the  course  of  the  malady  at  which 
elimination  occurs  is  fully  shown  in  the  following  table  also 
from  the  same  monograph. 

*  Revue  Mensuelle  de  Med.  et  de  Chir.,  1878,  tome  ii.   p.  255. 


2  per  cent. 

of  the  cases. 

.   6    „ 

•  38    „ 

•  40 

•  44    „ 

•  46    „ 

COURSE    AXD    PROaXOSIS. 


385. 


1 

case. 

0 

cases 

8 

M 

U 

J) 

3o 

5> 

34 

5» 

1:^ 

rj 

9 

)J 

3 

11 

3 

('■0 

Spontaneous  elimination  occurred 

At  the  end  of  3  days  ia 

-t      »       ■ 
„  5  to     7  days  in 

8  to  10      „      . 
n  to  14      „      . 
After  the  3rd  week,  in   . 
„      4th 

„      :2nd  month,  in 
„      4th 
.,      6tli 
After  about  one  yeai',  in 

It  must  not  be  supposed,  however,  that  when  spontaneous 
elimination  has  occurred,  cure  and  recover}^  must  necessarily 
follow. 

Over  40  per  cent,  of  the  patients  who  have  been  the 
subjects  of  elimination  of  the  bowel  die  from  effects  directly 
connected  with  the  intestinal  lesion  or  with  the  elimination 
process  itself.  The  mortality  after  separation  is  a  little  lower 
in  colic  invaginations  than  it  is  in  the  remaining  forms,  and 
is  conspicuously  affected  by  the  age  of  the  patient.  If  one 
excepts  the  very  young,  it  may  be  said  that  the  older  the 
patient  the  greater  becomes  the  probability  that  elimination  of 
the  bowel  will  be  followed  by  death.  In  patients  between 
eleven  and  twenty  years  of  age  the  deaths  after  spontaneous 
separation  are  only  28  per  cent. ;  in  those  between  twenty-one 
and  forty  years  32  per  cent. ;  between  lorty-one  and  fifty  the 
percentage  of  deaths  rises  to  36,  and  in  patients  between  lifty- 
one  and  sixty  years  of  age  to  50  per  cent.  In  patients  above 
sixty  years  of  age  the  mortality  is  as  high  as  85  per  cent. 

it  would  appear,  therefore,  from  Leichtens tern's  statistics, 
that  out  of  every  hundred  cases  of  intussusception  of  all 
kinds  some  fifteen  patients  may  be  expected  to  recover  in 
consequence  of  the  spontaneous  elimination  of  the  invaginated 
bowel.  ]My  impression  is  that  this  proportion  is  far  too  high. 
Cases  of  spontaneous  elimination  ending  in  cure  are  apt  to 
be  more  certainly  reported  than  are  cases  ending  in  death, 
and  I  would  venture  to  think  that  the  prospect  of  recovery 
in  intussusception  depending  upon  spontaneous  elimination  is 
represented  by  considerably  less  than  10  per  cent,  of  the  total 
number. 

It  only  remains  now  to  consider  what  are  the  modes  of 
death  after  spontaneous  elimination  of  the  gangrenous 
intestine. 

In  the  first  place,  it  often  happens  that  the  separation 
is  in  a  sense  premature,  and  occurs  before  the  parts  about 
the  neck  of  the  mass  have  become  securely  fused  together. 
z 


386  INTUSSUSCEPTION. 

After  the  intussusceptum  lias  been  removed  a  perforation 
or  rupture  occurs,  through  which  fsecal  matter  escapes  into 
the  peritoneum,  leading  to  a  fatal  peritonitis. 

Or  the  fusion  of  the  parts  about  the  neck  may  be  perfect 
but  slight.  The  gangrenous  segment  in  its  passage  along 
the  intestine  blocks  the  canal ;  some  obstruction  occurs ; 
the  gut  above  the  obstructed  point  becomes  distended,  and 
a  rupture  occurs  along  the  line  of  separation  of  the  gan- 
grenous intestine. 

In  another  set  of  cases  persistent  ulceration  remains  about 
the  elimination  line.  This  may  lead  to  chronic  diarrhoea, 
which  may  in  time  prove  fatal,  or  may  cause  death  much 
more  readily  by  producing  a  perforation.  This  and  like 
perforations  may  either  open  upon  the  peritoneal  surface 
or  into  the  subperitoneal  tissue.  In  the  latter  instance  a 
large  faecal  abscess  is  produced,  and  the  fatal  issue  more 
or  less  dela3^ed. 

A  part  of  the  intussusceptum  may  remain  and  may  lead 
to  a  new  invagination,  which  in  its  turn  may  prove  fatal. 

Some  patients  die  of  haemorrhage  incident  to  the  separa- 
tion of  the  gangrenous  gut."^  Others  perish  from  intestinal 
toxsemia  or  from  pyaemia,  and  of  this  form  of  death 
Mr.  Holmes  has  recorded  an  excellent  example,  t 

Rafinesque  has  discovered  two  recorded  cases  of  gangrene 
of  one  of  the  lower  limbs  following  upon  elimination  of 
invaginated  bowel.  In  both  these  instances  it  is  probable 
that  the  result  was  brought  about  by  thrombosis  of  the 
iliac  veins. 

Stricture  of  the  intestine  may  follow  from  cicatrisation 
at  the  line  of  elimination,  and  the  stricture  so  produced 
may  cause  in  its  turn  fatal  obstruction.  Such  an  occurrence 
is,  however,  very  rare.  It  is  true  that  some  narrowing  of  the 
parts  may  take  place  after  the  separation,  as  is  well  shown 
in  Fig.  11 4  J  I  have  had  under  m}^  care  a  case  in  which 
certain  slight  and  chronic  symptoms  of  obstruction  were 
probably  due  to  such  narrowing.  Recovery  following  upon 
elimination  is  not  very  uncommon,  yet  I  cannot  find  in 
any  of  the  museums  in  London  a  straightforward  case  of 
stricture  of  a  marked  kind  following  upon  intussusception, 
nor  have  I  discovered  any  recorded  cases  (save,  perhaps, 
one  mentioned  below)  where  such  a  circumstance  has  with- 
out doubt  occurred.     It  would  appear,  then,  that  stricture  of 

*  A7)ier.  Joi/rn.  Med.  Sciences,  vol.  xii.,  p.  372. 
t  Path.  Soc.  Trans.,  vol.  xix.,  p.  207. 

X  Roya,l  College  of  Surgeons  Museum,  Xo.  1377.  For  another  example, 
us  Dr.  Hare's  case;  Path.  Soo.  Trans.,  vol.  xiii.,  p.  86. 


COURSE    AND    PWGXOSIS.  337 

the  intestine  of  a  grade  sutficient  to  cause  fatal  obstruction 
must  be  excessively  rare  as  a  result  of  the  elimination  ot 
the  gut  in  invagination. 

In  one  case  of  stricture  of  the  lesser  bowel  which  is 
supposed  to  have  followed  invagination  there  is  no  history 
of  a  piece  of  gut  having  been  passed,  nor  indeed  any  evidence 
that  the  patient — a  woman  of  thirty-eight — had  ever  had 
intussusception.  This  patient,  moreover,  had  a  cicatricial 
stricture  in  her  gullet,  and  a  cicatrix  in  her  stomach  which 


Fig.   114. — Contraction  of  Colon  after  the  separation  of  an  Intussusception. 

a,  ileum  ;    h,  colon  ;    c,  Ciecuiii  ;    d,  seat  of  contraction. 

had  greatly  deformed  that  viscus.  In  the  absence  of  more 
complete  evidence,  it  may  be  suggested  that  the  cicatrix  in 
the  jejunum  was  due  to  the  same  cause  that  produced  the 
two  other  cicatrices.* 

The  solitary  case  alluded  to  above  is  placed  on  record  b}' 
Dr.  Fuller.  It  concerns  a  patient,  aged  twenty-two,  who  died 
of  subacute  intussusception  of  the  ileum.  When  twelve 
years  old,  she  had  had  a  severe  attack  of  colic  attended  by 
vomiting  and  much  pain  in  the  iliac  region.  The  symptoms 
subsided  in  seven  days.  She  had  since  then  been  much 
troubled  with  constipation.  The  autopsy  revealed  no  less 
than  thirty  polypoid  growths  in  the  lesser  bowel.  Four  and 
a  half  feet  above  the  ctecum  the  ileum  presented  a  cicatricial 
stricture,  as  if  from  an  ulcer,  the  bowel  here  resembling  the 

*  Dr.  Bristowe  ;  Path.  Soc.  Trans.,  vol.  x\.,  p.  ISO. 


388  OBSTEUflTION.  BY    GALL    STONES. 

ileo-csecal  valve.  It  may  in  this  case  be  surmised  that  the 
attack  at  the  age  of  twelve  was  due  to  an  intussusception, 
brought  about  perhaps  by  a  polyp,  and  that  the  cicatrix  had 
resulted  from  the  separation  of  the  involved  part. 

This  conclusion,  however,  can  be  nothing  more  than  a 
surmise. 

Among  the  signs  that  mark  the  separation  of  gangrenous 
bowel  are  the  following :  The  evacuations  commonly  become 
exceedingly  foul,  and  blood  often  appears  in  the  stools,  together, 
with  small  shreds  of  matter  that  on  examination  prove  to 
be  gangrenous  fragments  of  intestine.  The  elimination  may 
be  preceded  by  absolute  constipation  and  by  severe  symptoms 
of  obstruction ;  or  it  may  be  preceded  by  a  profuse  and 
sudden  diarrhoea.  After  the  separation  is  complete  there  is 
usually  a  cessation  of  symptoms,  with  the  exception  of  some 
diarrhoea,  which  may  persist  for  a  while. 

Finally  it  must  be  remembered  that  in  many  patients 
the  elimination  occurs  too  late  to  save  life,  and  the  sufferer 
dies  of  the  effects  of  the  intussusception  rather  than  from 
any  evils  incident  to  its  separation. 

One  point  remains.  On  page  168  a  case  has  been  alluded 
to  where,  as  a  result  of  limited  gangrene,  a  rent  formed  in 
the  inner  and  middle  layers  of  an  invagination  tumour 
whereby  the  intestinal  contents  were  able  to  pass  between 
the  intussusceptum  and  the  intussuscipiens.  This  is .  the 
only  example  I  can  find  of  what  may  possibly  prove  to  be 
one  other  mode  of  spontaneous  cure. 

4.  Obstruction  by  Gall  Stones. — As  has  been  already 
indicated,  in  dealing  with  the  clinical  features  of  this  form 
of  intestinal  obstruction,  the  course  of  the  trouble  may  vary- 
considerably  both  in  duration  and  in  the  severity  of  the 
symptoms. 

There  is  no  doubt  but  that  by  far  the  greater  majority  of 
all  gall  stones  that  find  their  way  into  the  intestine  pass 
through  that  canal  without  causing  any  definite  disturbance. 
Biliary  calculi  are  common  enough,  but  the  instances  in 
which  they  cause  intestinal  obstruction  may  be  regarded  as 
comparatively  rare,  and  indeed  as  very  rare.  Leichtenstern 
in  a  total  of  1,152  cases  of  intestinal  occlusion  from  various 
causes  includes  only  forty-one  examples  of  obstruction  by 
gall  stones. 

When,  however,  the  calculus  does  cause  obstruction  of 
the  bowels,  the  results  are  usually  disastrous.  In  the  cases 
which  I  have  myself  collected,  I  find  that  in  35  per  cent, 
of  the  examples  in  which  the  stone  caused  definite  and  severe 
symptoms   of    obstruction    the    patients    recovered    by   the 


VOURSTf:    AND    PROGNOSIS.  389 

spontaneous  passage  of  the  stone,  and  that  in  the  remaining 
Go  per  cent,  the  patient  died  or  was  in  a  few  examples  reheved 
by  operation. 

Among  280  cases  of  intestinal  obstruction  due  to  gall 
stones  collected  by  Schiiller,  Dufort,  and  Courvoisier,*  the 
mortality  is  given  as  52  per  cent. 

Kermisson  and  Rochard,t  dealing  with  a  collection  of 
105  cases,  give  the  death-rate  as  50  per  cent. 

Lobstein  J  has  collected  ninety-two  instances  of  obstruc- 
tion by  gall  stones.  Sixty-one  of  these  were  not  treated 
by  operation,  and  of  this  number  twenty-nine  died.  Thirty- 
one  were  treated  by  operation,  and  of  this  number  nineteen 
died. 

When  obstruction  symptoms  are  produced  by  gall  stones 
they  are  nearly  always  acute. 

The  duration  of  the  obstruction  may  vary  from  one  to 
twenty-eight  days. 

In  the  cases  which  end  in  recoveiy  the  average  duration 
of  the  obstruction  is  seven  days,  and  in  those  which  end 
in  death  tive  to  ten  days. 

In  one  instance  reported  by  Sargent  §  the  patient  died 
in  half  an  hour  apparentl}^  from  collapse. 

Spontaneous  evacuation  of  the  stone  may  occur  even 
after  symptoms  of  great  severity.  Thus,  in  a  case  recorded 
by  Dr.  C.  Martin  the  patient  suffered  from  absolute  obstruc- 
tion lasting  six  days,  the  vomiting  became  severe  and  was 
at  last  stercoraceous.  But  on  the  morning  of  the  seventh 
day  a  motion  was  passed  which  was  followed  by  the  evacua- 
tion of  a  large  stone.  The  patient  rapidly  recovered. ||  The 
concretion  had  a  circumference  of  three  and  a  half  inches. 

In  a  case  reported  by  Hutchinson^  the  symptoms  were 
very  acute,  and  on  the  sixth  day  it  was  considered  that 
the  patient  was  dying.  On  the  morning  of  the  seventh 
day,  however,  she  passed  a  gall  stone  one  inch  in  diameter 
and  made  a  perfect  recovery. 

In  another  case,  quoted  by  Dr.  Sands,  a  woman,  aged 
fort}',  suffered  from  obstruction  due  to  the  impaction  of 
a  gall  stone.  The  constipation  was  complete  for  four  weeks. 
At  the  end  of  that  time  a  motion  was  passed,  and  seven 
days  later  a  biliary  calttilus  with  a  circumference  of  three 
inches.      Stercoraceous  vomiting   commenced   on   the   third 

*  Mayo  Robson;  Diseases  of  the  Gall  Bladder,  1897,  p.  86. 
t  Archives  Generales  de  Med.,  Feb.,  1892. 
X  Beitriige  zar  klin.  Chirurgie,  bd.  xiii.,  heft  2. 
^  Urif.  Med.  .Journ.,  1879. 
IJ  Bull,  de  la  Soc  Anat.,  1875,  p.  070.     Paris. 
ll  Archives  of  (Surgery,  1802,  vol.  iii.,  p.  9. 


390  OBSTEUCIION   BY    GALL    STONES. 

day  and  lasted  for  three  weeks.  The  patient  had  boon 
treated  by  aperients  and  by  enemata.  She  made  a  good 
recovery."^ 

Rehef,  however,  may  be  afforded  by  other  means  than 
the  escape  of  the  stone  by  the  natural  passages.  The  im- 
pacted stone  may  excite  inflammation,  which,  passing  on 
to  suppuration,  may  produce  a  fistula  discharging  upon  the 
surface,  and  through  this  fistula  the  calculus  may  be  ex- 
pelled. Leichtenstern  well  observes  that  this  mode  of  cure 
is  extremely  rare,  but  quotes  no  example.  I  have  found  a 
recorded  case  that  bears  very  directly  upon  this  matter. 
It  concerned  a  child,  aged  ten,  who  had  been  liable  for 
some  time  to  attacks  ot  indigestion  and  bilious  vomiting. 
Some  time  after  one  of  these  attacks  a  fluctuating  swelling 
appeared  in  the  right  side  of  the  back.  This  was  incised, 
and  some  thin,  foetid  brown  pus  escaped.  The  discharge 
was  followed  in  four  days  by  the  evacuation  of  a  body 
the  size  of  a  nutmeg.  This,  when  cleared  of  fseces,  showed 
a  nucleus  the  size  of  a  large  pea  composed  wholly  of 
cholesterin.     The  child  did  well.t 

In  another  instance  an  abscess  was  set  up  by  the  process 
involved  by  the  passing  of  a  calculus  from  the  gall  bladder 
to  the  duodenum.  This  abscess  was  evacuated  externally, 
and  through  it  the  stone  might  readily  have  passed.  + 

I  have  myself  twice  opened  abdominal  abscesses,  in  the 
cavities  of  which  I  discovered  loose  gall  stones. 

Some  of  those  who  die  from  the  effects  of  obstruction 
die  from  mere  exhaustion  and  intestinal  toxsemia,  others 
succumb  to  acute  peritonitis,  and  a  comparatively  small 
number  to  perforation  of  the  bowel  above  the  seat  of  the 
impaction. 

Mr.  Ward  has  placed  upon  record  a  case  of  cicatricial 
stricture  of  the  terminal  part  of  the  ileum,  which  was, 
without  much  doubt,  due  to  ulceration  set  up  by  impacted 
and  long-retained  gall  stones.  |] 

*  JVew  York  Med.  Eecorrl,  vol.  xxxi.,  1882,  p.  427.     A  like   case  is  reported 
by  Dr.  Ormond;  Brit.  Med.  Journ.,  vol.  i.,  1897. 

t  Dr.  Thorowgood;  Path.  Soc.  Trans.,  1877,  p.  131. 

X  T'r.  Carrard;  Revue  Med.  de  la  Suisse  Bom.,  No.  2,  1882,  p.  82. 

II  Path.  Soc.  Trans.,  1852,  p.  357. 


391 


CHAPTER     VII 
CHRONIC  INTESTIXAL   OBSTRUCTION. 

GENERAL    DESCRIPTION    OF    A    CASE. 

History. — In  the  majority  of  the  examples  there  is  no 
element  of  interest  in  the  previous  history  of  the  patient. 
The  bowels  may  have  been  acting  regiilarly,  and  the  digestion 
may  have  been  perfect  up  to  the  time  of  the  commencement 
of  the  symptoms  of  obstruction. 

In  a  comparatively  few  cases  there  is  a  history  of  injury, 
of  hernia,  of  dysentery,  or  of  some  other  form  of  ulcera- 
tion of  the  bowel,  of  peritonitis  of  some  degree,  or  of 
persisting  constipation. 

These  previous  troubles  may  or  may  not  have  had  to 
do  with  the  stenosis  which  has  been  produced  in  the  bowel. 

In  general  terms,  it  may  be  said  that  the  previous  history 
of  the  patient  is  of  no  value  in  assisting  the  diagnosis,  and 
is,  indeed,  often  quite  misleading. 

Onset.— In  the  typical  case  the  onset  is  slow  and 
insidious,  and  the  patient  can  hardly  state  w^ith  precision 
when  the  symptoms  began.  The  initial  symptoms  are 
generally  grouped  under  the  heading  of  "  digestive  dis- 
turbances." There  is  definite  and  repeated  discomfort  in  the 
abdomen,  which  becomes  more  and  more  defined  and  more 
and  more  painful.  These  early  symptoms  need  not  be  asso- 
ciated with  any  constipation,  and  they  very  often  do  not 
suggest  obstruction  of  the  intestine. 

it  will,  however,  generally  be  noticed  that  the  patient 
has  sought  relief  from  these  initial  symptoms  by  taking 
aperients. 

In  a  quite  small  proportion  of  the  cases  the  symptoms 
begin  more  or  less  abruptly,  the  patient  being  at  the  time 
apparently  in  sound  health.  In  such  examples,  no  phe- 
nomena  have    attended    the    narrowin'j;  of  the    bowel,    until 


392  CEEONIG    INTESTINAL    OBSTRUCTION. 

one  day  the  stenosed  part  becomes  blocked  by  a  mass  of 
undigested  food,  or  by  hardened  fteces,  or  the  bowel  at  the 
affected  part  becomes  kinked  or  bent  upon  itself. 

It  is  needless  to  say  that,  the  more  fluid  the  contents  of 
the  bowel,  the  more  slowly  do  the  symptoms  develop,  and 
also  the  more  likely  are  there  to  be  sudden  manifestations 
by  reason  of  accidental  blocking  of  the  gut. 

The  general  course  of  chronic  intestinal  obstruction  is 
irregular,  the  patient  being  now  better  and  now  worse,  and 
the  progress  of  the  case  is  apt  to  be  marked  by  obstructive 
attacks  which  become,  in  time,  more  frequent,  more  serious, 
and  more  abiding. 

Pain.  —  The  pain  occurs  in  paroxysms,  and  is  distinctly 
of  the  nature  of  colic.  It  is  a  griping  pain.  It  comes  on  m 
attacks  which,  as  the  case  progresses,  increase  in  frequency, 
in  intensity,  and  in  duration.  The  interval  between  the 
attacks  decreases.  The  paroxysms  may  last  for  a  period 
ranging  from  a  few  minutes  to  several  hours 

The  pain  may  be,  to  a  certain  extent,  localised,  especially 
when  the  obstruction  is  in  the  colon. 

The  patient  associates  with  it  some  movement  or  struggle 
in  the  bowel.  Usually  the  pain  is  very  definitely  increased 
by  purgatives,  especially  when  the  trouble  is  well  advanced. 
The  administration  of  an  aperient,  on  the  other  hand,  has 
led  to  the  first  manifestations  of  the  trouble. 

Between  the  attacks,  the  patient  feels,  during  the  early 
stages  of  the  affection,  free  from  abdominal  discomfort.  But 
as  the  stenosis  becomes  narrower  the  interval  between  the 
attack  is  marked  by  a  sense  of  distension  and  uneasiness 
which  increases  in  degree  until  at  last  the  patient  is  never 
free  from  some  amount  of  abdominal  pain.  When  the 
obstruction  becomes  complete,  the  pain  becomes  continuous. 

Vomiting. — This  is  not  a  marked  symptom.  There  is 
nausea  during  the  early  attacks  probably,  and  this  may  pass 
on  into  vomiting  at  a  later  period. 

In  general  terms,  it  may  be  said  that  in  chronic  ob- 
struction the  vomiting  is  not  pronounced,  appears  late,  is 
scanty,  uncertain,  infrequent,  and  but  rarely  stercoraceous. 
When  the  obstruction  becomes  complete,  the  vomiting 
is  a  prominent  and  distressing  feature  and  assumes  a 
stercoraceous  character. 

State  of  the  Bowels. — Constipation  is  the  rule.  In  a  small 
proportion  of  cases  the  bowels  have  acted  regularly  until 
towards  the  end.  It  is  needless  to  saj^  that  constipation  is 
a  much  more  marked  feature  of  stenosis  of  the  colon  than 
it  is  of  stenosis  of  the  small  intestine.     In  stricture  of  the 


SYMPTOMS.  393 

small  intestine  the  bowels  ujay  act  with  perfect  regularity. 
A  normal  stool  may  be  passed  daily  in  a  case  in  which  there 
is  a  stricture  as  low  down  as  the  sigmoid  flexure.  For 
example,  Nothnagel  reports  the  case  of  a  woman,  aged 
fifty-eight,  who  was  in  vigorous  health  until  a  certain  day, 
when  she  was  seized  with  violent  colic.  Up  to  this  day  she 
had  worked  with  her  usual  energy  as  a  laundress,  and  had 
passed  a  normal  stool  every  day  without  aperients.  The 
attack  of  colic  was  repeated  daily,  and  on  the  seventh  day 
she  developed  symptoms  of  intestinal  obstruction  and  for 
the  first  time  sought  medical  advice.  She  died  suddenly 
of  collapse  on  the  tenth  day,  and  the  autopsy  revealed  a 
cancerous  stricture  of  the  lower  end  of  the  sigmoid  flexure 
Avhich  would  not  admit  the  little  finger. 

However,  as  has  been  already  stated,  constipation  is  the 
rule  in  all  forms  of  chronic  intestinal  obstruction,  and  this 
constipation  becomes  more  and  more  obstinate  as  the  case 
progresses,  mitil  at  last  it  appears  to  resist  all  attempted 
measures  to  give  relief  A  time  comes,  towards  the  end — 
and  often  some  time  before  the  end — when  aperients  have 
to  be  discontinued  on  account  of  the  intense  pain  and 
collapse  they  produce. 

In  stricture  of  the  colon  the  motions  passed  often  give 
evidence  of  having  been  very  long  retained. 

When  the  stenosis  involves  the  colon,  the  patient  is 
almost  certain  to  present  at  some  time  during  the  progress 
of  the  disease  the  phenomena  of  spurious  diarrhoea.  The 
lower  down  the  obstruction,  the  more  marked  and  the  more 
common  is  this  curious  symptom.  Indeed,  it  is  in  cancer 
of  the  rectum  that  it  is  met  with  in  its  most  pronounced 
ibrm. 

In  all  cases  of  abiding  and  unexplained  diarrhoea  in 
adults,  it  is  very  essential  that  an  examination  should  be 
made  of  the  rectum. 

A  certain  amount  of  diarrhoea  may  attend  cases  of 
stenosis  of  the  lesser  bowel  and  be  due  to  the  same  causes 
which  lead  to  that  symptom  when  the  colon  is  involved. 

In  the  section  on  the  morbid  anatomy  of  obstruction  of  the 
bowel  (page  16)  an  account  is  given  of  the  changes  which 
take  place  in  the  gut  above  the  stenosed  part.  The  bowel 
becomes  hypertrophied,  its  blood-vessels  become  engorged, 
and  its  mucous  membrane  becomes  irritated  by  the  presence 
of  long-retained  decomposed  matters  and  congested  by  reason 
of  the  abiding  distension  of  the  bowel  walls. 

There  results,  therefore,  a  catarrh  of  the  bowel  above  the 
stricture.     This  leads   to  a  copious   mucous  discharge,   and 


394  CHRONIC    INTESTINAL    OBSTBUCTION. 

this  watery  materitil,  carrying  with  it  a  certain  amount  of 
suspended  fsecal  matter,  escapes  at  the  anus  as  a  loose 
evacuation,  which  is  frequently  repeated.  Thus  patients 
Avith  obstruction  of  the  bowel  may  complain  that  their 
bowels  are  always  acting,  that  "  everything  runs  through 
them,"  and  that  they  dare  not  take  an  aperient  for  fear  of 
increasing  the  persisting  diarrhoea.  This  spurious  diarrhoea 
may  last  for  a  few  days  or  persist  for  many  weeks,  and  I  have 
known  it  continue  for  months.  When  it  is  of  short  duration, 
it  alternates  with  obstinate  constipation,  so  that  the  bowels 
either  do  not  act  at  all  or  are  acting — according  to  the 
patient's  estimate — too  freely. 

There  is  no  doubt  but  that  this  diarrhoea  is  a  natural 
method  of  giving  relief  to  the  overloaded  bowel,  as  it  washes 
away  a  not  inconsiderable  amount  of  retained  faeces,  and 
relieves  the  distended  blood-vessels.  The  patient,  however, 
is  usually  conscious  of  the  fact  that  the  relief  is  trifling  and 
imperfect,  and  often  feels  that  the  bowel  is  still  loaded. 

A  striking  feature  of  this  spurious  diarrhoea  is  the  in- 
tensely foul  odour  of  the  motions  which  are  passed — an  odour 
which  is  not  easily  forgotten. 

Sometimes  the  catarrh  which  leads  to  this  diarrhoea  is 
attended  with  a  considerable  discharge  of  mucus,  which 
is  to  be  recognised  in  the  evacuations.  This  mucus  may 
be  stained  with  blood,  even  in  cases  of  non-malignant  stric- 
ture of  the  colon.^ 

I  have  known  a  patient  with  cancer  of  the  rectum  pass 
through  a  left  inguinal  colotomy  wound  two  and  more 
teacupfuls  of  clear,  white,  jelly-like  mucus  in  a  day.  When 
a  stricture  exists,  the  mucus  is  retained,  for  the  most  part, 
until  it  has  been  liquefied  by  decomposition.  It  is  only 
from  an  artificial  anus  that  I  have  seen  large  masses  of  white 
transparent  mucus  poured  out.  What  escapes  from  the 
normal  anus  appears  as  a  thin  fluid,  or  as  those  shreds  of 
skin-like  material  which  are  common  in  colitis. 

As  a  matter  of  fact,  the  spurious  diarrhoea  of  chronic 
obstruction  of  the  colon  is  due  to  colitis. 

Blood  may  appear  in  the  motions  in  cases  of  stenosis 
of  the  bowel,  but  it  is  an  uncommon  symptom,  except  in 
cancer  of  the  rectum,  and  is  usually  quite  slight  in  degree. 

A  fairly  copious  bleeding  higher  up  in  the  intestine  may 
give  rise  to  peculiarly  stinking  stools,  which  German  writers 
have  described  as  having  a  "  carrion-like  smell." 

The  Shape  of  the  Motions. — This  is  a  matter  to  which 
considerable  attention  has  been  directed  in  luost  descriptions 

*  Dr.  Doyle's  case  ;  Trans,  of  the  Royal  Acad,  of  Med.  in  Ireland,  1892,  p.  81. 


SYMPTOMS.  395 

of  stenosis  of  the  bowel.  In  such  accounts  particular  im- 
portance is  attached  to  "  pipe-like  "  or  "  tape-like  "  motions, 
and  to  solid  stools  which  show  grooves,  or  marks,  or  spiral 
indentations  on  their  surfaces.  It  is  assumed  that  these 
peculiarities  of  conformation  are  given  to  the  fsecal  column 
by  the  narrow  strait  through  which  it  has  passed. 

The  shape  and  size  of  the  motions  are  of  very  little  value, 
however,  in  the  diagnosis  of  stricture  of  the  bowel,  and  are 
often  most  misleading. 

The  part  of  the  alimentary  canal  which  is  the  most 
concerned  in  the  shaping  of  the  motions  is  the  sphincter, 
and  the  very  great  majority  of  tape-like  or  rod-like  stools 
are  the  work  of  that  muscle. 

After  an  operation  for  piles  the  shape  of  all  solid  motions 
may  be  permanently  altered.  A  fissure  of  the  anus  may 
lead  to  rod-like  motions,  and  there  is  a  condition  of  irritable 
sphincter  which  is  invariably  attended  by  motions  which  have 
been  evidently  squeezed  through  a  narrow  strait. 

A  flattened  motion  may  be  caused  by  a  very  enlarged 
prostate,  or  by  a  uterine  fibroid,  Or  any  other  pelvic  tumour 
which  may  bulge  into  the  rectum. 

With  stools  altered  in  shape  and  size  stenosis  of  the  bowel 
has  little  to  do. 

Stricture  of  the  lesser  intestine  can  have  no  possible  effect 
upon  the  size  and  outUne  of  motions  passed  by  the  anus. 
Even  if  the  contents  of  the  ileum  Avere  of  sufficient  con- 
sistence to  receive  an  impression  from  a  narrowed  passage 
in  the  bowel,  the  peculiarity  of  contour  could  not  possibly 
be  maintained  by  the  fgecal  mass  during  its  passage  from 
the  csecum  to  the  external  sphincter. 

The  same  applies  to  strictures  of  the  ileo-cscal  valve, 
and  of  the  right  and  middle  portions  of  the  colon.  It  is 
conceivable  that,  when  the  stricture  is  situated  in  the  trans- 
verse colon,  a  motion  which  has  passed  the  strait  may  be 
hurried  unaltered  through  the  rest  of  the  colon,  and  may 
be  passed  at  the  anus  with  distinguishing  marks  upon  it. 
Such  a  circumstance,  however,  must  be  very  exceptional. 

I  have  known  rod-like  and  tape-like  motions  to  have  been 
passed  in  cases  of  stenosis  situated  in  the  descending  colon  and 
sigmoid  flexure,  especially  when  diarrhoea  has  followed  upon 
a  long  constipation.  The  circumstance  is,  however,  rare, 
and  when  it  occurs  is  of  little  or  no  diagnostic  value.  After 
all,  the  narrowing  of  the  solid  faecal  matter  passed  may 
be  due  to  the  sphincter. 

It  is  well  to  remember  that  it  is  in  the  ampulla  of  the 
rectum  that    the   motion   to    be  passed  is,  as  a  rule,  finally 


396  CHRONIC    INTESTINAL    OBSTRUCTION. 

moulded.  I  have  known  a  mass  of  long-retained  stony  faeces 
in  the  rectum  to  render  tape-like  the  more  recent  motions 
which  have  passed  by  it  and  escaped. 

I  have  also  known  a  large,  rounded  mass  of  fsecal  matter, 
the  size  of  a  hen's  egg,  to  be  passed  by  a  patient  who  had 
a  stricture  that  would  only  just  admit  the  forefinger,  and 
which  was  situated  only  six  inches  from  the  anus. 

In  stricture  of  the  rectum,  alteration  in  the  shape  of  the 
motions  passed  and  narrowing  of  their  width  is  common, 
and  in  strictures  low  down  is  usual.  With  the  rectal  cases 
of  stenosis  we  are  not  now  concerned. 

Speaking  generally,  the  sjanptom  under  discussion  is  of 
little  or  no  use  in  the  diagnosis  of  the  seat  of  the  mischief 
in  chronic  intestinal  obstruction. 

Constitutional  Symptoms. — The  subject  of  chronic  intes- 
tinal obstruction  becomes  enfeebled  and  wasted.  The  appetite 
is  impaired,  the  digestion  is  disturbed,  and  the  patient  is 
weakened  by  the  persisting  pain,  and  poisoned  by  products 
of  the  decomposition  which  is  proceeding  in  his  own  intestine. 
An  occasional  slight  rise  of  temperature  is  not  uncommon. 
It  may  last  only  for  a  day.  It  is  due,  probably,  to  septic 
absorption  from  the  bowel,  the  contents  of  which  have  been 
long  retained.  It  is  most  common  after  these  contents  have 
been  in  some  way  disturbed,  e.g.  by  movement,  massage, 
enemata,  or  aperients. 

Thus  in  cases  of  ftecal  accumulation  the  dislodgment  of 
the  long-retained  mass  is  very  commonly  followed  by  a  mild 
degree  of  fever,  which  is  of  short  duration. 

When  the  obstruction  is  due  to  malignant  disease,  there 
is  often  noticed  that  loss  of  colour,  of  weight,  and  of  vigour 
which  is  so  marked  a  feature  of  cancer.  In  due  time,  the 
cachexia  of  cancer  may  be  pronounced.  Certain  reservations, 
however,  must  be  made  with  regard  to  this  alteration  in  the 
patient's  aspect.  In  the  first  place,  the  symptoms  of 
obstruction  may  be  due  to  cancer,  and  yet  the  patient  at  the 
onset  of  the  trouble,  and  even  for  some  time  after,  appear  to 
be  in  excellent  general  health.  The  reason  of  that  is  this. 
The  malignant  growth  may  cause  intestinal  obstruction  while 
it  is  yet  very  small,  while  it  is  so  little  advanced  as  to  cause 
no  general  impairment  in  health  apart  from  that  due  to  dis- 
turbance of  the  bowel.  Epithelioma  of  the  bowel  may  cause 
grave  obstuction  when  it  is  scarcely  more  substantial  in 
bulk  than  a  heavy  wedding  ring  {see  Fig  95). 

In  the  second  place,  patients  with  obstructed  bowels  due 
to  any  cause  are  apt  to  become  ashen  or  yellowish  of  hue,  a 
chjmge  in  complexion  which  is  probably  due  to  the  absorption 


CONDITION    OF    THE    ABDOMEN.  397 

by  the  blood-vessels  of  those  colouring  uiatters  which  are 
lavishly  produced  by  the  disordered  intestine,  and  which 
are  expelled  from  the  body  rather  through  the  kidneys  than 
by  the  rectum. 

The  symptom  of  indicanuria  has  been  alluded  to  on 
page  320. 

Tenesmus  is  often  complained  of  when  the  obstruction 
is  situated  low  down  in  the  colon,  and  is  a  feature  in 
chronic  intussusception,  especially  when  the  colon  is 
involved. 

Condition  of  the  Abdomen. — The  abdomen  may  present 
a  quite  normal  appearance,  especially  when  the  stenosis  con- 
cerns the  lesser  intestine,  or  when  the  trouble  is  yet  in  its 
earlier  stages.  As  a  rule,  however,  there  is  some  distension 
of  the  abdomen,  and  the  degree  of  it  varies  with  the  site  and 
rigour  of  the  obstruction.  Towards  the  end  of  a  case  of 
stricture  of  the  colon  the  distension  of  the  abdomen  may  be 
enormous.  The  increased  proportions  of  the  belly  depend 
partly  upon  an  accumulation  of  intestinal  contents,  and  partly 
upon  meteorism. 

The  meteorism  varies,  and  undergoes  fluctuation  from 
time  to  time.  When  it  is  considerable,  the  abdomen  is  made 
prominent  and  barrel-like.  When  it  is  absent,  the  loaded 
coils  of  bowel — especially  those  formed  by  the  colon — tend  to 
gravitate  into  the  loins  when  the  patient  is  recumbent,  and  to 
produce  a  wide,  flat  abdomen  very  easily  mistaken  for  the 
appearance  of  the  abdomen  in  ascites. 

An  evidently  loaded  bowel  associated  with  diarrhoea  is 
a  striking  feature,  when  present,  of  chronic  intestinal  obstruc- 
tion. The  diarrhcjea  in  such  case  will  be  of  the  spurious  type 
above  alluded  to  (page  393). 

The  abdominal  wails  remain  flaccid  except  in  the  presence 
of  peritonitis. 

Two  very  prominent  and  conspicuous  features  are  present 
in  chronic  intestinal  obstruction,  or  at  least  during  the  most 
characteristic  stages  of  that  affection,  viz.  rumbling  and 
gurgling  sounds  in  the  bowels,  and  visible  coils  of  intestine 
in  movement. 

Both  these  symptoms  are  due  to  that  disordered  and  per- 
sistent peristaltic  movement  which  is  a  feature  in  chronic 
obstruction.  The  movement  is,  of  course,  in  the  bowel  above 
the  stenosed  part.  That  bowel  is  more  or  less  distended, 
its  canal  is  more  or  less  loaded,  and  its  walls  are  more  or 
less  thickened.  The  bowel  is  making  a  persistent  effort  to 
overcome  the  obstruction,  and  to  rid  itself  of  some  of  its 
accunuilated  contents. 


398  GHBONIC    INTESTINAL    OBSTRUCTION. 

These  efforts  are  expressed  by  the  painful  cohcky  attacks 
which  are  a  marked  feature  of  the  affection. 

As  the  pain  conies  on,  gurghng  and  bubbUng  sounds  are 
to  be  heard,  and  beneath  the  probably  thinned  parietes  visible 
coils  of  intestine  are  seen  to  stand  out  in  relief 

The  gurgling  sounds  are  often  very  loud,  and  can  be  heard 
at  a  distance.  They  are  described  by  many  terms  and  ex- 
pressions. Sometimes  there  are  sounds  as  of  air  bubbling 
through  water :  at  other  times  there  are  whistling  or  squeak- 
ing sounds,  which  may  be  associated  with  rumbling  and 
rushing  noises  and  soiuids  as  of  water  running  or  splashing 
within  a  confined  space. 

It  is  quite  evident  that  these  noises  are  due  to  peristaltic 
movements,  which  are  affecting  large  and  resonant  coils  of 
bowel  with  thickened  walls  and  with  copious  contents  com- 
posed of  gas  and  fluid  matters. 

The  quantity  of  fluid  in  the  bowel  is  often  greatly  increased 
by  the  persistent  taking  of  aperients. 

The  visible  movements  in  the  bowel  are  apt  to  be  excited 
by  movement  of  the  patient,  by  even  the  removal  of  the  bed- 
clothes and  by  the  placing  of  a  cold  hand  upon  the  abdomen. 
An  account  of  these  visible  movements  has  already  been 
given  on  pag^e  304. 

They  are  induced  by  aperients,  and  also  by  food  when 
the  small  intestine  is  concerned. 

They  are  very  conspicuous  in  long-standing  cases  in  which 
the  colon  is  involved,  and  in  Avhich  the  parietes  are  attenuated. 
The  surface  of  the  abdomen  becomes  uneven.  A  rounded 
elevation  appears  in  one  place  and  depressions  appear  in 
another.  They  produce  an  aspect  comparable  to  that  of  a 
"  relief-map  "  of  a  hilly  country.  Slowly  the  hill-like  eleva- 
tion sinks  and  vanishes,  and  out  of  the  shalloAv  valleys 
appear  fresh  eminences,  which  rise  up  and  move  along  be- 
neath the  skin.  The  movements  are  slow  and  attended  by 
colicky  pain  and  by  more  or  less  of  the  rumbling  and  gurgling 
sounds  which  have  just  been  described. 

The  same  coil  appears  again  and  again,  and  can  be  often 
quite  definitely  recognised. 

I  have  already  discussed,  on  page  315,  the  question  of  the 
identification  of  individual  coils,  so  that  some  light  may 
be  thrown  upon  the  possible  site  of  the  obstruction. 

It  is  needless  to  say  that  coils  of  the  colon  form  larger 
elevations  than  do  loops  of  the  lesser  bowel.  At  the  same 
time,  a  hypertrophied  small  intestine  may  be  represented 
by  visible  coils  in  movement  which  can  be  aptly  described 
as  enormous. 


If 

BALLOONING    OF    THE    llEOTUM.  399 

Movements  arc  less  slow  in  the  small  intestine  than  in  the 
large. 

In  certain  cases  of  chronic  obstruction — notably  in  ex- 
amples of  cancer  of  the  bowel,  of  intussusception,  and  of 
faBcal  accumulation — a  tumour  may  be  discovered  in  the 
abdomen.  These  tumoiu's  are  discussed  in  the  sections 
which  follow  upon  the  specific  forms  of  chronic  obstruction. 

Ballooning  of  the  Rectum. — The  term  ballooning  of  the 
rectum  is  applied  to  a  condition  of  the  terminal  part  of 
the  bowel  in  which  it  is  found  to  be  dilated  and  fixed,  as 
it  were,  in  the  dilated  condition,  like  a  pupil  which  has 
been  dilated  by  atropine.  The  term  "  ballooning  "  is  a  mis- 
nomer, because  the  rectum  is  not  distended  nor  blown  out 
by  gas.     Its  condition  is  due  to  some  phase  of  paralysis. 

This  peculiar  state  of  the  bowel  is  described  on  page  413, 
to  which  section  the  reader  is  directed. 

In  relation  to  the  present  subject  it  only  remains  to  be  said 
that  ballooning  of  the  rectum  is  often  met  with  in  association 
with  stricture  of  the  colon,  and  especially  with  cases  in  which 
the  stenosis  involves  the  descending  colon  or  sigmoid  flexure. 
It  is  not  by  any  means  an  invariable  feature  even  in  stric- 
tures in  these  latter  situations.  Ballooning  of  the  rectum 
is  also  met  with  in  conditions  other  than  those  in  which 
the  bowel  is  stenosed.  These  conditions  are  alluded  to  on 
page  414.  So  far  as  one  can  rely  upon  an  experience  which 
has  not  been  definitely  tabulated,  I  am  under  the  impression 
that  the  majority  of  the  examples  of  ballooning  of  the  rectum 
are  in  association  with  stricture  of  the  left  side  of  the  colon. 


I.     STENOSIS    OF    THE    SMALL    INTESTINE. 

Under  this  heading   the   following   different  varieties   of 
obstruction  of  the  lesser  bowel  may  be  classed: — 

1.  Some  cases  of  bending  of  adherent  small  intestine  (page  87). 

2.  Some  cases  of  adhesions  binding  a   portion   of   the  bowel  into 

a  fixed  loop  (page  9.3). 

3.  Cases  of  compression  of  the  gut  by  adhesions  (page  88). 

4.  Cases  of  matting  together  of  several  coils  of  intestine  (page  96). 

5.  Cases  of  narrowing  of  the  gut  from  shrinking  of  the  mesentery 

(page  101). 

6.  Some  instances  of  volvulus  (page  346). 

7.  Obstruction  by  neoplasms  (pige  259). 

8.  Some  cases   of   obstruction    by   gall   stones   and   foreign  bodies 
^   (page  368). 

9.  Some  cases  of  compression  by  a  tumour  outside  the  gut  (page  272). 
10.  Stricture    of    the    small    intestine     either    malignant    or    non- 
malignant  (page  202). 


400  STRICTURE    OF    THE    SMALL    INTESTINE. 

Of  these  different  forms  the  last  named  is  the  most  famihar, 
the  most  precisely  defined,  anatomically  and  clinically,  and  the 
most  common. 

In  the  account  which  follows,  the  symptoms  described 
will  be  those  of  strictm'e  of  the  small  intestine,  since  that 
lesion  is  the  type  of  all  forms  of  chronic  obstruction  in  the 
lesser  bowel. 

Certain  of  the  varieties  above  tabulated  are  ver^"  rare, 
and  some  are  merely  curious. 

All  these  forms  of  intestinal  obstruction  present  symptoms 
which  more  or  less  closely  resemble  one  another,  and  which 
find  their  typical  representation  in  a  case  of  stricture  of 
the  bowel.  In  each  instance  it  will  be  noted  that  there  is 
some  permanent  but  partial  occlusion  of  the  bowel. 

The  resemblance  between  these  various  forms  of  intestinal 
obstruction  is  so  close  that  a  certain  differential  diagnosis  is 
impossible. 

Any  distinctive  features  (such  as  they  are)  which  may 
be  associated  with  any  of  the  above  forms  of  obstruction 
will  be  found  detailed  in  the  accounts  given  of  each  of 
these  varieties  in  the  previous  parts  of  this  Avork  (references 
to  the  various  sections  are  given  on  page  399). 

In  the  first  four  forms  there  will  probably  be  some  history 
of  a  local  peritonitis  that  gave  rise  to  the  adhesions  producing 
the  obstruction,  or  there  will  have  been  manifestations  of 
tuberculous  peritonitis.  In  the  fifth  form  there  may  be  the 
same  feature  in  the  previous  history,  or  some  evidence  of 
mesenteric  gland  disease.  In  the  eighth  form  there  will  be 
the  history  associated  with  gall  stones  and  foreign  bodies, 
to  which  attention  has  been  directed.  In  the  ninth  varietv, 
the  tumour,  which  will  probably  have  origin  in  the  pelvis, 
may  in  many  instances,  be  obvious  upon  examination. 

Stricture  of  the  Small  Intestine. — History,  Age,  and 
Sex.  In  the  matter  of  sex  there  is  nothing  definite  to 
notice.  The  trouble  appears  to  be  about  as  common  in 
males  as  in  females. 

Non-cancerous  strictures  usually  occur  about  early  middle 
life,  while  cancerous  strictures  are  rare  before  forty.  Kcinig 
says  that  strictures  due  to  tuberculous  ulceration  are  most 
common  between  the  ages  of  twenty  and  thirty.  The  con- 
genital strictures  will  probably  make  themselves  manifest 
in  early  life. 

The  previous  history  of  the  case  is  seldom  of  any  clinical 
value.  In  the  non-cancerous  cases  there  may  be  a  history 
of  enteritis,  of  tuberculous  disease,  of  injur}^  of  strangulated 
hernia,  and  even  of  the  impaction  of  a  foreign  body. 


SYMPTOMS'.  ii)l 

The  part,  played  by  these  antecedent  conditions  is  dealt 
with  in  a  previous  section  of  this  book  (page  203),  and  the 
time  which  may  elapse  between  the  assumed  causative 
lesion  and  the  obstructive  phenomena  has  also  been  alluded 
to  in  the  section  referred  to. 

Mode  of  Onset  and  General  Course. — The  symptoms 
are  usually  extended  over  a  comparatively  long  period  of 
time,  and  become,  as  the  case  advances,  progressively  worse. 
The  stenosed  canal  simply  becomes  narrower  and  narrower, 
until  at  last  it  produces  a  degree  of  obstruction  which,  either 
from  its  long  duration  or  its  completeness,  leads  to  results 
that  produce  death.  Thus  it  happens  that  many  cases  of 
this  form  of  constriction  develop  very  slowly  and  very 
insidiously,  and  follow  a    tedious  and  long-extended  course. 

Before  detinite  obstruction  symptoms  develop  there  may 
be  a  period  marked  by  obstinate  digestive  troubles,  by 
"intestinal  indigestion,"  by  flatulence,  constipation,  and 
some  degree  of  wasting. 

Followin<^  upon  these  manifestations  the  phenomena  of 
obstruction  appear  gradually.  While  this  can  be  said  of 
many  cases,  it  cannot  be  said  of  the  majority.  Owing  to 
the  fluid  character  of  the  contents  of  the  small  intestine, 
it  happens  that  the  stenosis  may  become  anatomically 
pronounced  before  very  serious  clinical  symptoms  are  pro- 
duced. But  the  narrow  stricture  is  constantly  liable  to  be 
abruptly  closed.  A  valvular  fold  of  mucous  membrane  is 
laid  across  it,  or  it  becomes  suddenly  plugged  by  a  mass 
of  undigested  food,  or  the  involved  coil  of  gut  becomes 
abruptly  closed  by  kinking  or  by  some  of  those  methods 
of  producing  obstruction  which  depend  upon  adhesions. 

Thus  it  happens  that  in  the  clinical  history  of  stricture 
of  this  bovv^l  we  very  often  find  the  symptoms  beginning 
with  an  attack  of  almost  acute  obstruction. 

The  patient  may  recover  from  such  an  attack  by  the 
lumen  of  the  bowel  becoming  cleared,  and  the  phenomena 
of  obstruction  may  be  repeated  with  varying  degrees  of 
acuteness  over  and  over  again.  In  a  few  recorded  cases 
there  has  been  only  one  attack ;  it  has  been  sudden  and 
acute,  has  seized  the  patient  when  in  apparent  good  health, 
and  has  led  to  death  in  as  short  a  period  as  seven  to  ten 
days. 

Such  a  case  is  reported  by  Refrege.  It  concerns  a  man, 
aged  forty-nine,  who  had  been  liable  for  some  months  to 
constipation.  For  some  days  before  his  admission  into 
hospital  he  had  had  pain  in  the  lower  part  of  his  abdomen. 
On  admission  the  limbs  were  cold  and  cyanosed,  the  face  was 

A  A 


402  STRICTUBE    OF    THE    SMALL    INTESTINE. 

livid,  the  eyes  were  simken,  the  patient  "was  mucli  troubled 
by  Tomiting,  and  the  pulse  was  very  small  and  feeble.  There 
was  constipation.  An  epidemic  of  cholera  existed  at  the 
time,  and  the  case  was  taken  for  an  example  of  that 
disease.  The  patient  was  treated  with  hot  baths  and  by 
such  methods  as  were  then  in  Togue  for  the  treatment 
of  cholera.  He  died  on  the  eighth  da}"  after  adniission. 
Before  his  death  stercoraceous  vomiting  had  occurred,  and 
the  general  character  of  the  case  had  been  recognised.  The 
autopsy  revealed  a  stricture  in  the  lower  ileum  that  would 
barely  admit  a  crow-quill.^  Another  very  interesting  case 
is  reported  by  Dr.  Piatt.  In  this  instance  the  patient,  a 
child,  aged  nine,  appears  to  have  had  no  evidence  of  previous 
abdominal  trouble.  The  symptoms  of  obstruction  appeared 
suddenly,  and  rapidly  assumed  an  aspect  of  great  gravity. 
Death  took  place  on  the  seventh  day.  The  case  had  been 
diagnosed  as  acute  intussusception.  The  autops}^  revealed 
a  stricture  of  the  lower  extremity  of  the  ileum,  which  had 
become  obstructed  by  a  plug  of  clayey  fteces.t 

It  is  needless  to  say  that  such  cases  do  not  belong  to 
the  category-  of  chronic  obstruction.  Such  abrupt  and 
intense  examples  of  obstruction  have  been  mistaken  for 
strangulation  of  the  bowel  by  a  band. 

It  win  be  evident  from  what  has  been  said  that  the 
coiu'se  of  a  case  of  stricture  of  the  lesser  bowel  is  imcertain, 
and  to  this  naay  be  added  the  fact  that  even  in  chronic 
cases  that  course  is  apt  to  be  extremely  irregular  and  to 
be  marked  by  gTeat  fluctuations. 

Pain. — The  most  conspicuous  and  most  constant  feature 
of  this  trouble  consists  in  certain  attacks  of  paroxj'snial  pain 
which  occur  at  intervals.  The  pain  in  these  attacks  is  of 
the  natm-e  of  coHc,  and  is  often  severe.  It  is  associated 
with  constipation,  and  is  usually  attended  by  some  degree 
of  vomiting.  The  colicky  pains  are  often  described  as 
radiating  from  the  navel,  and  are  never,  so  far  as  I  can 
ascertain,  distinctly  localised  in  any  one  part.  It  is  signifi- 
cant to  note  that  these  attacks  usually  come  on  after  food, 
and  as  a  rule  some  three  or  four  hours  after  the  taking 
of  the  food.  Sometimes  they  appear  at  a  shorter  interval 
after  meals,  but  very  rarely  at  a  longer.  These  attacks 
may  begin  most  insidiously,  may  appear  in  patients  who 
present  absolutely  no  abdominal  symptoms,  or,  as  is  more 
usual,  come  on  after  a  long-continued  intestinal  disturbance, 

*  Le  Dia^ostic  de  rEti-anglement  intestinal  k  Sympt6mes  choleriformes, 
by  Felix  Eefrei,'e.     Paris,  1867. 
+  Lancet,  vol.  i.,  1873,  p.  42. 


SYMPTOMS.  403 

sometimes  marked  by  diarrhcea,  but  more  often  by  constipa- 
tion. At  the  commencement  the  patient  complains  merely 
of  indigestion  and  flatulency  after  food.  In  time  the  attacks 
become  more  definite  and  more  severe,  until  at  last  the 
sufferer  is  liable  from  time  to  time  to  sharp  paroxysms 
of  colic  associated  with  vomiting  and  other  symptoms. 

In  other  instances  the  individual  attacks  are  somewhat 
severe  from  the  first.  They  may  appear  once  a  month  or 
once  in  three  or  four  months.  They  may  last  several 
hours  or  even  days.  During  the  intervals  between  their 
appearance  the  patient  may  be  well,  or  have  a  little 
indigestion,  or  be  tronbled,  as  is  very  common,  with  con- 
stipation, or  with  diarrhoea  alternating  with  constipation. 

In  any  case,  as  time  advances  the  attacks  occur  more 
and  more  fi'equently,  while  at  the  same  time  they  lessen 
in  duration.  At  last  the  patient  may  have  attacks  of 
pain  every  few  hours  or  every  quarter  of  an  hour,  each 
attack  lasting  probably  not  more  than  two  or  three 
minutes. 

The  severe  attacks — which  may  appear  at  long  intervials 
— are  no  doubt  due  to  the  temporary  blocking  of  the 
bowel  either  by  the  intestinal  contents,  or  b}^  the  bending, 
twisting,  or  kinking  of  the  gut.  These  attacks  may  be 
alarmingly  acute  while  they  last,  and  when  they  have 
passed  away  the  patient  may  remain  for  weeks  or  months 
free  from  an}^  gross  intestinal  discomfort. 

The  frequently  repeated  and  almost  continuous  attacks 
of  pain  (which  come  on  every  hour  or  less,  and  which  last 
some  minutes  only)  are  due  to  disordered  and  violent 
peristaltic  movements  in  the  hypertrophied  bowel  above  the 
stricture.  These  pains  are  in  time  associated  with  visible 
peristaltic  movements  and  with  rumbling  and  gurgling 
sounds. 

It  will  be  seen,  therefore,  that  the  painful  attacks  in 
stricture  of  the  bowel  are  represented  by  two  perfectly 
distinct  types,  one  due  to  blocking -of  the  lumen  of  the 
gut  and  one  due  to  a  violent  and  tumultuous  peristaltic 
convulsion  in  the  bowel 

The  association  of  these  attacks  with  the  ingestion  of 
food  is  a  matter  of  great  importance  and  of  much  diagnostic 
value.  Usually  the  patient  recognises  the  association  and 
has  to  exercise  great  care  in  his  diet.  In  several  instances 
the  attacks  have  been  warded  off  for  a  long  while  by  adopting 
a  perfectly  Huid  diet,  and  have  reappeared  at  once  on  any 
relaxtion  of  the  rule. 

It  is  weU  to  note  that  when  complete  obstruction  sets  in 


404  S  TRIG  TUBE    OF    THE    SMALL    INTESTINE. 

tlie  character  of  tlie  pain  changes.  It  becomes  continuous, 
being,  however,  at  the  same  time,  hable  to  exacerbations 
at  intervals.  UnUke  the  previous  attacks,  the  patient  is 
not  now  free  from  pain  in  the  intervals. 

Vomiting. — Vomiting  in  these  cases,  although  a  constant 
symptom,  is  by  no  means  a  pronounced  or  distressing  one. 
During  the  more  severe  of  the  obstructive  attacks  (attacks 
that  appear  early  in  the  case,  occur  at  long  intervals  and  last 
some  time)  vomiting  is  present.  It  even  then  appears 
late  and  is  often  scanty.  If  the  obstructive  attack,  how- 
ever, lasts  for  some  time  (a  matter  of  days),  the  vomiting 
is  apt  to  become  stercoraceous,  although  the  examples  of 
this  are  infrequent. 

As  a  rule,  the  vomiting  onl}^  becomes  stercoraceous  to- 
wards the  termination  of  the  final  attack  of  obstruction. 
On  the  whole,  vomiting  in  stricture  of  the  small  intestine 
is  a  symptom  subject  to  considerable  fluctuation.  It  is  late 
to  appear,  is  often  scanty,  and  is  very  rarel}'  stercoraceous. 
When  the  bowel  is  really  blocked,  then  the  vomiting  ma}^, 
of  course,  be  very  copious  and  very  -distressing. 

■  During  the  comparatively  minor  attacks  of  pain,  which 
become  the  most  conspicuous  feature  of  the  case,  there  is 
seldom  much  vomitmaf.  There  is  nausea  and  occasionallv 
some  sickness.  The  vomiting  seems  to  be  the  more  ready 
the  nearer  the  obstruction  is  to  the  stomach,  and  it  is  often 
distinctly  and  repeatedly  provoked  by  food. 

Constipation. — The  state  of  the  bowels  is  subject  to  great 
variation.  In  about  60  per  cent,  of  the  cases  constipation 
is  the  predominant  feature.  In .  something  less  than  40  per 
cent,  there  is  constipation  alternating  with  diarrhoea ;  but 
in  only  a  very  few  cases  is  diarrhoea  the  more  usual  condition 
of  the  bowels.  During  the  initial  obstructive  attacks,  and 
during  the  final  attack,  constipation  is  almost  invariable  and 
may  remain  absolute  for  many  days  or  even  for  two  or  for  three 
weeks.  The  constipation  at  first  yields  to  treatment,  but 
soon  becomes  more  and  more  obstinate. 

It  is  important  to  note  that  the  earlier  attacks  are  often 
at  once  relieved  by  an  aperient.  The  purge  would  not  only 
render  the  intestinal  contents  more  fluid,  but  would  remove 
the  cause  of  the  obstruction,  if  it  be  a  mass  of  undigested 
matter.     Like  relief  may  follow  the  use  of  an  enema. 

Sometimes  an  attack  of  long-continued  constipation  is 
suddenly  relieved  by  a  copious  and  spontaneous  stool.  In 
such  cases  the  plug  or  other  obstructing  agent  has  probably 
abruptl}^  yielded. 

It  is  not  very  uncommon  for  the  patient,    after  days  or 


SYMPTOMS.  405 

weeks  of  absolute  obstruction,  to  pass  a  copious  motion  just 
before  death. 

While  j)urgatives  give  distinct  relief  in  the  earlier  stages 
of  the  case,  they  usually  in  the  course  of  time  add  greatly  to 
the  patient's  distress  by  increasing  the  intensity  of  the  futile 
peristaltic  movement  in  the  hypertrophied  bowel. 

In  one  case  of  cancer  involving  the  lower  part  of  the 
ileum  there  were  severe  and  repeated  haemorrhages  from  the 
anus.  The  case  was  associated  with  persistent  diarrhoea."^  I 
have  not  met  with  any  other  example  of  this  symptom.  In 
a  few  cases  of  malignant  disease  of  the  lesser  bowel  melgena 
has  been  reported. 

Constitutional  Symptoms. — As  regards  the  general  con- 
dition of  the  patients,  it  only  remains  to  be  said  that  they 
become  progressively  weaker  as  the  disease  advances,  being 
worn  out  by  the  frequent  attacks  of  pain  and  vomiting  and 
enfeebled  by  the  loss  of  appetite,  the  impaired  condition  of 
digestion  and  the  consequent  malnutrition.  Emaciation  is 
usually  pronounced,  and  the  patient's  wasted  and  cachectic 
aspect  may  be  such  as  to  suggest  the  presence  of  malignant 
disease,  even  in  the  case  of  a  simple  stricture. 

When  malignant  disease  does  exist  in  the  bowel,  the 
emaciation  and  loss  of  strength  are  more  marked,  appear 
earlier,  and  advance  more  rapidly. 

The  question  of  indicanuria  is  discussed  on  page  308. 
Septic  absorption  from  the  bowel  may  lead  to  occasional 
elevations  of  temperature. 

In  only  one  recorded  case  do  I  find  any  account  of 
tenesmus.  It  was  in  a  case  of  stricture  following  strangu- 
lated hernia,  and  was  apparently  very  slightly  marked.  The 
stenosis  was  in  the  lower  part  of  the  ileum,  t 

The  Condition  of  the  Abdomen. — The  abdominal  walls 
remain  flaccid  except  during  some  of  the  more  painful 
paroxysms,  or  after  the  development  of  peritonitis,  or  during 
a  long-abiding  obstruction. 

During  the  duration  of  the  attacks  of  obstruction  there 
will  be  some  meteorism,  which,  however,  is  never  excessive. 
In  the  intervals  between  the  attacks  the  abdomen  need 
not  be  swollen,  and  its  walls,  indeed,  may  be  retracted, 
especially  m  cases  associated  with  much  wasting  and  diar- 
rhoea. In  the  latter  stages  of  the  case  there  will  be  more 
or  less  abiding  meteorism. 

It  is  very  usual  for  the  movements  of  the  intestinal  coils 
to  be   visible  through  the   parietes,  a   circumstance  that   is 

*  Bull,  do  la  Soc.  Anat.  de  Paris,  1875.  p.  299. 

t  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  tome  vi.,  1880,  p.  607;  M.  Berger. 


406  STBIGTUBE    OF    THE    SMALL    INTESTINi]. 

to  be  especially  noted  during  the  paroxysms  of  pain.  This 
symptom  is  one  of  the  utmost  importance.  It  indicates 
the  presence  of  a  long-abiding,  incomplete  obstruction  and  of 
hypertrophied  coils  above  it.  It  indicates  also  an  advanced 
stage  of  the  trouble.     {See  page  304.) 

In  no  instance  among  the  recorded  non-malignant  cases 
was  any  tumour  formed  by  the  stricture  to  be  felt,  nor  any 
localised  dulness  present  that  could  assist  in  the  diagnosis 
of  the  ailment. 

In  the  cases  of  cancer  a  tumour  has  been  detected  in 
some  80  per  cent,  of  the  recorded  cases."^ 

Areas  of  dulness  due  to  an  accumulation  of  fluid  in 
the  gut  above  the  stricture  are  fairly  common.  Equally 
common  is  it  to  obtain,  on  palpation,  splashing  sounds  as 
of  water  in  a  membranous  bag.     (See  page  398.) 

Rumbling  and  gurgling  sounds  are  commonly  heard, 
and  are  audible  to  others  than  the  patient.  They  are 
especially  noticed  during  the  attacks  of  pain.  These  sounds, 
together  with  the  movements  of  visible  coils,  are  much 
increased  by  purgatives.     (See  page  398.) 

Except  in  the  presence  of  complications,  the  abdomen, 
in  cases  of  stricture  of  the  small  intestine,  is  not  tender. 

Stricture  of  the  Duodenum. — ^Stenosis  of  the  bowel  in 
this  situation  calls  for  a  few  words  of  special  comment. 

Consenital  strictures  of  the  duodenum  are  described 
on  page  232. 

Both  cicatricial  and  malignant  strictures  have  been  met 
with  in  this  part  of  the  bowel,  t 

Malignant  growths  in  the  duodenum  are  ver}^  rare. 
Owing  to  the  large  size  of  the  duodenum  and  the  fluid 
character  of  the  matter  which  passes  through  it,  the  symptoms 
of  stricture  in  this  part  are  but  slowly  developed. 

When  the  stricture  is  situated  in  the  duodenum  above 
the  point  of  entry  of  the  common  bile  duct,  the  symptoms 
produced  are  hardly  to  be  distinguished  from  those  of 
stricture  of  the  pylorus.  There  are  gross  evidences  of  gastric 
disturbance  with  pain  in  the  epigastrium,  vomiting  at  in- 
tervals, dilatation  of  the  .stomach,  loss  of  appetite,  and 
wasting.  When  the  stenosis  is  due  to  a  cancerous  growth, 
there  may  be  liEematemesis,  and  a  definite  tumour  may 
sometimes  be  felt  in  the  right  hypochondriac  region. 

*  See,  for  example,  a  case  by  Morton  ;   Path.  Soc.  Tians.,  1893,  p.  89. 

t  Cicatricial  Stricture.  See  Lange  :  Annals  of  Surgery,  vol.  i.,  1893,  j).  588. 
Malignant  Growths.  See  Kast  and  Rumpel ;  Illustrations  of  Path.  Anat., 
part  iii.,  and  Whittier ;  Trans,  of  the  Assoc,  of  American  Physicians,  1889, 
p.  292.  Sarcoma,  Eolleston.  See  Trans.  Path.  Soc,  1892,  p.  67.  Moore; 
Ibid.,  1883,  p.  99. 


SYMPTOMS'.  407 

When  tlie  stricture  is  at  or  below  the  entrance  of  the 
common  bile  duct,  there  is,  in  addition  to  the  gastric 
symptoms  above  alluded  to,  a  copious  vomiting  of  bile, 
together  with  possible  jaundice  and  not  infrequently  with 
dilatation  of  the  gall  bladder.  The  symptoms,  indeed,  are 
closely  allied  to  those  of  cancer  of  the  head  of  the  pancreas 
in  which  the  lumen  of  the  gut  is  encroached  upon. 

The  contents  of  the  stomach  are  commonly  said  to  be 
neutral  or  alkaline  in  these  cases,  and  to  include  pancreatic 
secretion. 

Constipation  is  common,  there  is  no  meteorism,  and 
indeed  the  abdomen  is  usually  quite  Hat  or  even  sunken  in. 
Allusion  has  been  made  on  page  299  to  a  case  of  Dr.  Pye 
Smith's,  in  which  the  vomited  matter  in  an  example  of 
stricture  of  the  duodenum  is  said  to  have  had  "  a  decidedly 
fsecal  odour." 

Sometimes  it  has  been  noticed  in  these  duodenal  cases 
that  a  few  hours  after  the  stomach  has  been  washed  out 
there  is  a  copious  vomiting  of  bile-stained,  ill-smelling 
matters.  This  represents  fluid  which  was  lodged  in  the 
dilated  duodenum  when  the  stomach  was  being  washed  out, 
and  which  was  poured  into  that  viscus  soon  after  it  had 
been  artificially  emptied.  The  persistent  flowing  of  large 
quantities  of  bile  into  the  stomach  is  a  conspicuous  symptom 
— when  present — of  duodenal  stricture.  In  some  reported 
cases  the  dilatation  of  the  duodenum  above  the  stricture 
has  been  simply  enormous.  One  writer  says  that  the 
duodenum  could  hardly  be  distinguished  from  the  stomach, 
so  large  had  the  bowel  become. 

Generally  speaking,  the  vomiting  in  cases  of  duodenal 
stenosis  appears  early,  and  is  distinctly  influenced  by  food. 
Stricture  of  the  Ileo-caecal  Valve. — No  distinctive 
features  attend  stricture  of  this  part.  They  are  for  the 
most  part  identical  with  those  associated  with  stenosis  of 
the  small  intestine,  except  that  the  vomiting  is  usually 
slighter,  and  symptoms  are  not  induced  by  taking  food.  In 
some  examples — the  minority — the  symptoms  resemble  those 
of  stenosis  of  the  colon."^ 

>  Among  ten  recorded  examples  I  have  collected,  two 
patients  died  of  causes  not  directly  connected  with  the 
obstruction.  In  the  remaining  cases  there  was,  among 
other  symptoms,  vomiting  which  became  stercoraceous  in 
three  instances,  remained  non-stercoraceous  in  four,  and 
is  indefinitely  described  in  one  example.  In  each  instance 
the  general   condition   of   the   bowels   was   that   of  chronic 

*  &e  case  by  Ih-.  Raymond  Johnson;  Path.  Sue.  Trans  ,  1889,  p.  112. 


i08  8  TRIG  TUBE    OF    THE    COLON. 

constipation.  In  one  case  only  was  any  tumour  detected.  As 
regards  tlie  duration  of  tlie  symptoms,  in  one  recorded  case 
tliey  appear  to  have  existed  for  less  than  one  month  before 
death.  In  this  example  the  valve  was  occluded  by  a  new 
growth.  In  Dr.  Wickham  Legge's  case,  alluded  to  on 
page  21,  obstruction  symptoms  had  existed  at  intervals  for 
at  least  eleven  3^ears.  It  is  supposed  that  the  stricture  was 
in  this  instance  congenital.  In  the  remaining  cases  the 
average  duration  of  the  symptoms  before  death  was  seven 
months. 

Two  j)atients,  as  already  noted,  died  of  causes  not  directly 
connected  with  the  obstruction.  Of  the  rest,  two  died 
after  operation,  two  from  perforation,  while  four  succumbed 
to  the  effects  of  long-continued  obstruction  of  the  bowel. 

II.    STENOSIS   OF   THE    COLON. 

Under  this  heading  the  following  different  varieties  of 
obstruction  of  the  colon  may  be  classed : — 

1.  Some  cases  of  beDdiug  of  adherent  colon  (page  86), 

2.  Compression  of  the  gut  by  adhesions  (page  90). 

3.  Some  cases  of  volvulus  of  the  csecum  (page  345). 

4.  Obstruction  by  neoplasms  (page  259). 

6.  Compression  by  a  tumour  outside  the  gut  (page  269). 

6.  Some  cases  of  enterolith  (page  372). 

7.  Stricture  of  the  colon  (page  202). 

The  onl}^  common  form  of  obstruction  is  the  last-named — 
stricture  of  the  colon.  This  represents  the  type  of  chronic 
obstruction  of  the  large  intestine,  and  in  the  following  account 
the  symptoms  given  are  the  symptoms  of  stricture. 

The  symptoms  associated  with  the  other  varieties  will 
be  found  detailed  in  the  accounts  given  of  them  in  previous 
chapters.  These  symptoms  generally  accord  with  those  of 
stricture  of  the  colon,  and  the  features  in  the  differential 
diagnosis  are  never  marked.  Some  diagnostic  value  attaches 
to  the  previous  history  of  the  patient,  as  has  been  already 
pointed  out  in  connection  with  the  different  forms  of 
obstruction  that  resemble'  stricture  of  the  lesser  bowel 
(page  400). 

Stricture  of  the  Colon. — History,  Age,  and  Sex.  In 
the  matter  of  age  and  sex  and  previous  history  there  are 
the  same  circumstances  to  be  noted  Avhich  have  been  detailed 
in  dealing  with  stricture  of  the  lesser  bowel  (page  400). 
Certain  examples  have  been  recorded  of  cancer  of  the  colon 
in  quite  3'oung  patients,  and  this  has  led  to  the  statement 
made  by  some  writers  to  the  effect  that  cancer  at  an  early 


SYMPTOMS.  409 

ao^e  is  more  often  met  witli  in  the  colon  than  elsewhere. 
The  youngest  patients  upon  whom  I  have  operated  for 
cancer  of  the  large  intestine  were  a  woman  aged  twenty- 
three  and  a  man  aged  thirty. 

To  what  has  been  said  of  the  previous  history,  in  dealing 
with  the  small  intestine,  must  be  added  the  circumstances 
in  connection  with  the  colon,  of  colitis,  dysenter}^,  syphilitic 
and  tuberculous  ulceration. 

Mode  of  Onset  and  General  Course. — The  resemblance 
between  the  clinical  aspect  of  stricture  of  the  lesser  bowel 
and  stricture  of  the  colon  is  close,  and  in  general  outline 
the  two  affections  follow  a  nearly  identical  course  marked 
by  symptoms  of  the  same  common  type.  In  many  instances 
it  is  difficult  and  indeed  impossible  precisely  to  differentiate 
between  stenosis  situated  in  the  two  segments  of  the  in- 
testine. 

Pain. — The  most  conspicuous  symptom  consists  of  attacks 
of  paroxysmal  pain  which  appear  at  intervals.  These  attacks 
resemble  those  already  described  in  dealing  with  the  lesser 
bowel.  They  may  be  the  first  indications  of  the  disease, 
but  usually  appear  after  some  such  intestinal  disturbance 
as  chronic  constipation,  or  constipation  alternating  with 
diarrhoea.  The  earlier  attacks  depend,  no  doubt,  upon  some 
temporary  obstruction  of  the  stricture  ;  the  later  paroxysms 
of  pain  on  disordered  peristaltic  movements.  These  two 
causes  of  pain  have  been  already  considered  (page  294).  The 
pain  is  usually  less  severe  than  is  the  case  in  the  paroxysms 
attending  stricture  of  the  small  intestine. 

The  interval  of  time  between  the  earlier  attacks  is  often 
considerable.  Thus  in  one  case  nine  months  elapsed  between 
the  first  and  second  attacks.  In  other  instances  there  have 
been  three  or  four  attacks  a  year  for  some  years.  As  the 
stricture  narrows  these  occurrences  become  more  frequent 
and  more  troublesome. 

Unlike  the  strictures  of  the  small  intestine,  stenosis  of 
the  colon  is  generally  unattended  by  definite  symptoms  of 
the  nature  of  indigestion.  There  is  usually  no  connection 
between  the  attacks  of  pain  and  the  ingestion  of  food. 
Indeed,  in  only  one  of  the  recorded  cases  have  I  found 
this  connection.  The  case  in  question  was  one  of  simple 
stricture  at  the  hepatic  flexure.  Attacks  of  pain  and 
vomiting  came  on  some  two  or  three  hours  after  nearly 
every  meal,  so  that  the  patient  at  last  became  almost  afraid 
to  eaf^ 

The  attacks  in  cases  of  stenosis  of  the  lesser  bowel  are 

*  Bull,  de  la  Soc.  Anat.,  1870,  p.  322. 


410  STRICTURE    OF    THE    COLON. 

commonly  relieved,  at  first  at  least,  by  the  administration 
of  a  purge.  In  cases,  however,  involving  the  colon  the 
opposite  obtains.  Aperients  are  apt  to  aggravate  existing 
symptoms,  a  circumstance  which  depends,  no  doubt,  upon 
the  more  solid  character  of  the  contents  of  the  larger  bowel. 
The  final  obstruction  is  usually  preceded  by  many  attacks 
of  paroxysmal  pain.  Between  these  attacks  the  patient  may 
feel  fairly  well,  although  he  is  usually  troubled  by  con- 
stipation, or  by  constipation  alternating  with  diarrhcea  and 
with  much  flatulence.  When  the  obstruction  becomes  abso- 
lute, the  character  of  the  pain  changes,  just  as  is  the  case 
in  the  small  intestine ;  it  ceases  to  be  distinctly  intermittent 
and  becomes  more  continuous. 

The  cases  in  which  the  stricture  is  due  to  cancer  appear 
to  be  attended  by  more  pain  than  obtains  in  the  examples 
of  simple  stricture ;  possibly  this  is  due  to  the  fact  that 
the  patient's  general  condition  in  malignant  disease  renders 
him  less  tolerant  of  pain.  Severe  pain  in  the  back  is  not 
uncommon  in  cancer  of  the  colon,  especially  in  cancer  of 
the  sigmoid  flexure. 

In  one  recorded  case  the  malady  appears  to  have  actually 
commenced  with  severe  pain  in  the  back  which  lasted  for 
two  or  three  months.  Here  also  the  growth  was  in  the 
sigmoid  flexure."^ 

I  have  known  a  case  of  cancer  of  the  caecum  in  which 
most  of  the  pain  was  complained  of  in  the  left  iliac  fossa. 
Examples  of  this  "  crossed  pain "  are  not  uncommon  in 
the  abdomen. 

An  increase  in  the  pain  just  before  the  bowels  act  is 
not  uncommon,  especially  when  the  stricture  is  low  down 
in  the  colon  on  the  left  side. 

Vomiting. — Vomiting  is  even  less  marked  in  stenosis 
of  the  colon  than  in  that  of  the  small  intestine.  In  the 
earlier  attacks  it  may  be  entirely  absent.  In  the  majority 
of  cases  it  tends  to  appear  late  and  be  very  scanty.  In 
the  graver  attacks  vomiting  is  more  frequent,  and  in 
the  final  attack  it  is  constant.  It  is  seldom  a  distressing- 
symptom,  and  often  fluctuates  in  severity,  being  sometimes 
absent  for  days  even  during  the  final  obstructive  attack. 
It  is  rarely  stercoraceous  except  during  the  obstruction  that 
immediately  precedes  death.  Even  in  such  a  circumstance 
the  cases  of  stercoraceous  vomiting  are  to  those  of  non- 
stercoraceous  vomiting  as  5'  to  7.  So-called  fasculent 
vomiting  depends  more  upon  the  duration  and  completeness 
of  the  occlusion  than  upon  its  situation  in  the  colon.     There 

*  Lancet,  vol.  i.,  1875,  p.  369. 


SYMPTOMS.  411 

are,  however,  some  striking  exceptions  to  this.  Thus,  in 
three  cases  aUuded  to  below,  where  the  duration  of  complete 
constipation  was  respectively  eighty-eight,  tliirty,  and  forty- 
six  days,  the  vomiting  was  not  severe  and  never  became 
stercoraceous. 

In  another  case  the  ejected  matters  did  not  become 
stercoraceous  until  the  fourteenth  day  of  absolute  consti- 
pation, the  patient  dying  about  the  sixteenth  da}^  Other 
things  being  equal,  stercoraceous  vomiting  is  the  more 
common  the  higher  up  the  obstruction  is  in  the  colon. 

Sometimes  the  vomiting  appears  at  fairly  regular 
intervals,  as  in  one  case  of  stricture  of  the  sigmoid  flexure, 
where  the  patient  vomited  every  half-hour  with  some 
regularity. 

In  one  case  of  cancer  of  the  colon  reported  by  Dr. 
Bristowe  vomiting  occurred  during  the  early  obstructive 
attacks,  but  not  during  the  final  obstructive  attack  which 
preceded  death.^ 

Constipation. — The  prevailing  condition  of  the  bowels 
is  one  of  chronic  constipation  that  is  now  and  then  asso- 
ciated with  a  little  spurious  diarrhoea,  just  as  is  seen  in 
cases  of  stricture  of  the  rectum.  In  thirty  cases  of  simple 
stricture  constipation  was  the  prevailing  condition  in  twenty- 
three  instances.  In  the  remaining  seven  examples  there 
was  constipation  alternating  with  marked  diarrhoea. 

In  thirty  cases  of  cancer  of  the  bowel  attended  with 
stricture  there  was  marked  constipation  in  fifteen  examples, 
and  constipation  alternating  with  diarrhoea  in  twelve  in- 
stances, while  in  the  remaining  three  cases  diarrhoea  was 
the  predominant  feature.  It  will  be  seen,  therefore,  that 
diarrhoea  is  more  common  in  cases  of  cancer.  The  diarrhoea 
in  stenosis  of  the  colon  is  of  the  type  known  as  "spurious 
diarrhoea,"  which  has  been  fully  considered  on  page  394. 

In  a  few  rare  cases  the  diarrhoea  may  depend  upon  a 
fistulous  communication  between  the  colon  and  the  small 
intestine.  Such  a  case  is  reported  by  Dr.  Raymond  Johnson.t 
Here  a  mass  of  columnar-celled  epithelioma,  producing 
stricture,  was  found  in  the  transverse  colon  of  a  woman 
of  sixty-four.  The  stricture  would  admit  the  little  finger. 
To  the  malignant  mass  the  ileum  was  adherent,  and  the 
ulcerating  growth  had  led  to  a  fistulous  communication 
between  the  transverse  colon  and  the  ileum  at  a  point 
five  feet  distant  from  the  termination  of  that  intestine. 
The  fistulous  opening  admitted  the  little  finger. 

*  Path.  Soc.  Trans.,  vol.  xxiii.,  p.  119. 
t  Ibid.,  1889,  p.  111. 


412  STRICTURE    OF    THE    COLON. 

The  patient  had  suffered  for  two  years  from  increasing 
distension  of  the  abdomen  and  increasing  constipation. 
Three  days  before  her  death  diarrhoea  set  in.  The  motions 
were  noticed  to  be  watery  and  pale  yellow  in  colour,  and 
there  is  no  doubt  but  that  they  were  formed  by  the 
contents  of  the  ileum,  which  had  passed  directly  into  the 
transverse  colon. 

If  the  patient  die  of  intestinal  obstruction,  the  final 
attack  is  usually  characterised  by  absolute  constipation. 
Nothing  may  pass  the  rectum  for  ten  or  twenty  days 
before  death.  In  some  cases  the  period  of  absolute  con- 
stipation has  exceeded  these  limits,  and  has  attained  a 
duration  of  thirty^  and  forty-six  days,t  and  even  of  eighty- 
eight  days,  as  occurred  in  a  case  of  cancer  of  the  bowel 
reported  by  Mr.  Cooper  Forster.J  During  the  earlier  attacks 
there  is  also  constipation. 

The  constipation  at  first  yields  to  aperients  or  enemata, 
but  in  time  becomes  more  and  more  obstinate.  Enemata 
usually  act  more  directly  than  purgative  medicines.  It 
has  been  shown  that  in  some  cases  water  can  be  injected 
through  the  stricture  from  below,  but  not  from  above. 

In  the  earlier  stages  of  the  case  definite  relief  usuall}^ 
follows  the  administration  of  purgatives,  but  as  the  stricture 
becomes  more  narrow  aperients  cause  intense  pain,  increasing 
the  already  excessive  peristaltic  movements  and  forcing  the 
intestinal  contents  against  the  obstruction. 

No  action  of  the  bowels  will  in  time  follow  upon  the 
taking  of  purgatives,  in  spite  of  the  intense  colic  produced. 

In  not  a  few  instances  which  have  come  under  my 
notice  very  acute  symptoms  have  followed  upon  the  giving 
of  a  smart  aperient.  There  has  been  not  only  violent 
colic,  but  also  vomiting  and  a  certain  degree  of  collapse. 
I  have  known  death  to  follow  in  twenty- four  hours  after  the 
administration  of  a  strong  purgative  in  a  case  of  rigorous 
stricture  of  the  colon. 

In  more  than  one  example  one  notices  in  the  history 
of  cases  that  the  true  nature  of  the  trouble  was  first 
revealed  by  the  disastrous  disturbance  induced  by  an  un- 
fortunately-timed aperient. 

In  about  15  per  cent,  of  all  cases  of  cancer  of  the 
colon  a  bloody  discharge  from  the  anus  has  been  observed. 
In  the  larger  proportion  of  these  cases  the  stricture  is  in 
the  sigmoid  flexure. 

*  Dr.  Coupland;  Path.  Soc.  Trans.,  vol.  xii.,  p.  94. 

t  L'incet,  vol.  ii.,  1869,  p.  80. 

X  Guy's  Hosp.  Eeports,  1869,  p.  377. 


SYMPTOMS.  413 

The  blood  is  usually  quite  trifling  in  amount,  although 
I  have  seen  an  instance  of  copious  hiijmorrhage  in  a  case 
of  cancer  of  the  sigmoid  flexure. 

It  is  to  b3  remembered  that  stricture  of  the  left  colon 
is  not  infrequently  associated  with  piles.  This  association 
is,  I  think,  much  more  frequent  when  the  stricture  is 
cancerous. 

Bloody  discharge  from  the  anus  will  not  be  met  with 
in  association  with  the  simple  stricture. 

I  am  not  aware  that  any  fragments  of  malignant  growth 
have  been  discovered  in  the  motions  in  cases  of  cancer 
of  the  colon. 

When  the  obstruction  involves  the  sigmoid  flexure,  the 
motions,  when  solid,  are  often  flattened  or  much  narrowed, 
or  are  grooved  or  fluted,  or  are  passed  with  a  spiral  outline. 
Such  stools  may  be  noticed  to  be  smeared  with  blood 
or  nuicus. 

The  question  of  the  importance  to  be  attached  to 
alterations  in  the  shape  of  the  motions  will  be  found 
discussed  on  page  394,  to  which  reference  should  be  made. 

Ballooning  of  the  Rectum. — This  term  is  appHed  to  the 
following  condition.  The  tinger  is  introduced  into  the  rectum, 
and  that  bowel  is  found  to  be  empty  and  to  have  its  walls 
apparently  dilated  to  the  utmost.  The .  finger,  after  passing 
the  sphincter,  appears  to  come  suddenly  into  an  open  space. 
It  requires  a  fair  range  of  movement  for  the  bowel  wall  to  be 
touched,  and  there  seems  to  be  quite  a  considerable  distance 
between  what  are  usually  opposed  surfaces  of  the  gut.  The 
rectal  wall,  when  touched,  appears  to  have  been  stretched 
and  to  have  become  fixed  in  the  stretched  condition.  The 
surface  is  smooth,  the  velvety  feeling  is  lost,  and  the  familiar 
rugae  have  vanished.  The  finger  seems  to  have  been  in- 
troduced into  an  empty  shell.  The  rectum  appears,  moreover, 
to  be  fixed,  and  gives  the  impression  of  being  a  mucous-lined 
cavity  with  rigid  walls  rather  than  the  lax  soft  tube  it  is. 

The  condition  is  due  to  some  disturbance  in  the  innerva- 
tion of  the  rectum,  and  is  due  to  no  mere  distension  of  the 
bowel.  It  disappears  under  an  anaesthetic,  but  is  not  made 
to  vanish  by  such  dilatation  of  the  sphincter  as  would  allow 
of  the  escape  of  gas. 

Ballooning  of  the  rectum  has  been  already  considered  in 
previous  sections  of  this  work.     {See  page  399.) 

Ballooning  of  the  rectum  is  often  met  with  in  association 
with  stricture  of  the  left  side  of  the  colon. 

It  is  not,  however,  alone  clue  to  this  condition.  It  may 
be  met  with  in  connection  with  tumours   about  the  pelvic 


1.14  8TBICTUBE    OF    THE    COLON 

brim  and  with  a  loaded  sigmoid  flexure  or  descending  colon 
in  cases  of  faecal  accumulation.  In  such  instances  it  is 
possible  that  the  innervation  and  blood-supply  of  the  rectum 
may  be  interfered  with  by  pressure.  I  have  met  with  this 
symptom  in  subacute  perityphlitis  and  in  certain  cases  in 
which  a  neurotic  element  is  conspicuous  in  the  general 
assemblage  of  the  patient's  symptoms. 

While  this  symptom  is  not  sufficiently  definite  in  its 
associations  to  be  diagnostic,  it  must  always  when  present 
raise  a  suspicion  of  stenosis  of  the  colon.  As  I  have  aheady 
said  (page  399),  I  believe  that  the  majority  of  the  examples 
of  ballooning  of  the  rectum  are  in  association  with  stricture 
of  the  left  side  of  the  colon. 

Oonstitutional  Symptoms. — The  general  condition  of  the 
sufferer  in  these  cases  ]na_y  be  expressed  in  the  same  words 
which  have  been  applied  to  the  cases  of  those  afflicted  with 
stricture  of  the  lesser  intestine. 

There  are  the  same  wasting,  the  same  loss  of  strength,  and 
in  cases  of  cancer  the  same  manifestations  of  anaemia  and 
cachexia.  Emaciation  proceeds  less  rapidly  when  the  colon 
is  involved  than  when  the  small  intestine  is  concerned.  I 
have  noticed  that  stricture  of  the  colon  is  often  attended  with 
very  marked  mental  dej)ression  bordering  sometimes  upon 
hypochondriasis.  Yeiy  often  in  cases  of  cancer  of  the  colon 
the  symptoms  of  obstruction  have  appeared  at  a  time  when 
the  patient  has  seemed  to  be  in  quite  perfect  health,  and  the 
very  condition  of  bodily  vigour  has  been  used  as  an  argument 
against  the  presence  of  mialignant  disease. 

Among  the  special  symptoms  of  stricture  of  the  colon 
must  be  noticed  tenesmus.  It  is  especially  apt  to  occur  in 
cases  of  stricture  low  down  in  the  colon  on  the  left  side,  and 
particularly  in  cases  attended  by  diarrhea.  I  think  it  is 
more  marked  in  the  early  than  in  the  later  stages  of  the 
disease  and  is  probably  not  present  in  more  than  one-third  of 
the  cases.  Tenesmus  Avould  appear  to  be  more  common 
in  examples  of  cancer  than  in  instances  of  non-malignant 
stricture. 

Strangury  is  very  uncommon  in  stenosis  of  the  colon 
above  the  confines  of  the  rectum. 

When  fever  exists,  it  is  due  either  to  some  septic  absorp- 
tion from  the  loaded  intestine  or  to  suppuration  about  the 
stricture. 

The  Condition  of  the  Abdomen. — The  abdominal  walls 
remain  flaccid  unless  there  be  great  distension  or  unless  some 
peritonitis  has  developed.  There  is  but  little  meteorism  so 
long  as  the  bowels  act,  and  in  cases  associated  with  persistent 


SYMPTOMS.  415 

diarrhoea  the  parietes  may  he  rotractcd.  As  the  obstruction 
becomes  more  complete  the  abdomen  becomes  more  and 
more  distended,  and  in  fatal  cases  there  may  be  a  consider- 
able enlargement  of  the  belly  by  the  time  that  death 
occurs. 

Often  the  outline  of  the  colon  distended  with  f«3cal  matter 
is  very  evident,  and  in  any  case  the  distension  is  most  marked 
in  those  parts  of  the  abdomen  which  are  occupied  by  the 
large  intestine.  The  outline  of  the  colon,  moreover,  may  be 
indicated  by  some  dulness  on  percussion,  while  the  region 
of  the  small  intestine  remains  tympanitic. 

Often  large  fsecal  masses  can  be  felt  in  the  bowel  above 
the  obstruction,  masses  so  prominent  as  sometimes  to  form 
very  distinct  tumours,  the  nature  of  which  has  not  always 
been  accurately  diagnosed. 

Coils  of  intestine  in  movement  are  very  apparent  through 
the  parietes.  Sometimes  these  hypertrophied  coils  are  quite 
enormous.  Movements  in  the  coils  are  associated  with 
colicky  pains,  with  loud  rumbling  and  gurgling  sounds  as 
of  the  bubbling  of  gas  through  water.  A  coil  on  percussion 
may  be  at  one  moment  resonant ;  then  when  a  peristaltic 
wave  passes  along  it  the  gas  which  causes  the  resonance  is 
driven  out,  and,  the  fsecal  matter  lodged  in  the  coil  alone 
remaining,  the  percussion  note  becomes  dull.  Coils  distended 
with  fluid,  giving  the  sense  of  membranous  bags  filled  with 
water,  are  often  to  be  made  out,  especially  after  aperients 
have  been  administered. 

The  subject  of  distended  coils  in  visible  movement  and 
of  the  gurgling  and  bubbling  sounds  heard  in  cases  of  chronic 
obstruction  is  dealt  with  on  pages  .'^04  and  315. 

In  cases  of  simple  stricture  no  tumour  is  to  be  felt,  but 
in  cases  of  malignant  disease  a  tumour  is  to  be  detected 
through  the  abdominal  walls  in  no  less  than  40  per  cent, 
of  the  examples. 

Any  tumour  which  exists  may  very  readily  be  concealed 
by  the  rigidity  of  the  abdominal  wall  or  by  the  existence 
of  even  a  moderate  degree  of  meteorism.  A  small  cancerous 
growth  in  the  hepatic  or  splenic  flexure  may  be  so  placed 
beneath  the  ribs  as  to  be  incapable  of  being  felt  from  the 
surface.  It  must  be  remembered  that  a  cancer  of  the  colon 
may  cause  a  fatal  obstruction  of  the  bowel,  and  yet  be  of 
quite  small  dimensions,  and  form  no  more  than  a  rigid 
and  narrow  rinsf  around  the  intestine. 

The  tumour,  when  it  exists,  appears  as  a  hard,  rounded, 
and  possibly  nodular  growth,  which  is  often  tender  on 
handling,  which  cannot  be  felt  at  all  times,  and  which  has 


416  STRICTURE    OF    THE    COLON. 

a  degree  of  mobility  corresponding  to  the  segment  of  the 
colon  in  which  it  occurs. 

The  tumour  may  appear  and  disappear  and  appear  again 
in  the  course  of  half  an  hour's  examination  of  the  abdomen, 
should  there  be  hypertrophied  coils  in  movement.  As  the 
bowel  about  the  tumour  undergoes  contraction  the  mass 
is  very  apt  to  come  prominently  forwards. 

Sometimes  the  tumour  is  absolutely  callous  on  handhng. 
Less  often  it  is  tender,  and  I  have  known  a  case  of  cancer 
of  the  sigmoid  flexure  in  which  the  tumour  was  always 
very  tender. 

It  is  to  be  remembered  that  ftecal  masses  are  very  apt 
to  be  lodged  above  the  stricture,  and  these  may  easily  be 
mistaken  for  the  growth  or  may  greatly  exaggerate  the 
apparent  size  of  the  growth. 

If  the  fgecal  mass  can  be  cleared  away  by  enemata  and 
aperients,  the  tumour  may  appear  to  vanish,  and  the  belief 
be  aroused  that  the  case  is  merely  one  of  fiEcal  accumu- 
lation. 

The  tumour  may  be  at  one  time  dull  on  percussion,  and 
at  another  time  resonant.  This  will  obviously  depend  upon 
the  relation  to  it  of  bowel  which  is  full  of  solid  fgecal  matter 
on  the  one  hand,  or  is  distended  with  gas  on  the  other. 

As  an  example  of  the  ease  with  which  the  surgeon  may 
be  deceived  with  regard  to  a  tumour  of  the  bowel,  the 
following  case,  reported  by  jSTothnagel,  may  be  given  : — 

A  woman,  aged  forty,  began  in  May  to  have  a  good  deal  of 
abdominal  discomfort  and  trouble  with  her  bowels.  By  June  she 
had  well-marked  phenomena  of  stricture  of  the  bowel,  marked  by 
paroxysms  of  colic,  by  visible  peristaltic  movements,  by  gurgling  in 
the  abdomen,  and  by  increasing  constipation.  In  July  a  tumour 
appeared  in  the  right  iliac  fossa ;  it  increased  when  the  bowels  were 
confined,  and  diminished  Avhen  they  were  ojjen.  It  was  hard,  uneven, 
and  tender.  The  symptoms  of  obstruction  became  more  and  more 
marked,  and  the  patient  became  weaker  and  emaciated.  In  October 
the  tumour  in  the  right  iliac  fossa  formed  a  hard,  unvarying  mass 
which  was  not  fixed,  and  which  was  diagnosed  to  be  a  cancerous 
tumour  of  the  colon.  In  November  an  abscess  formed  about  this 
tumour,  which  gave  vent  to  very  foul  pus  when  incised.  The  patient 
died  shortly  afterwards.  The  jxM-morUm  revealed  a  narrow  stricture 
at  the  commencement  of  the  ascending  colon.  The  terminal  part  of 
the  ileum  was  much  dilated,  and  in  it  was  lodged  a  large  collection 
of  cherry,  plum,  and  grape  stones.  These  stones,  closely  packed 
together,  had  formed  .  the  tumour,  which  had  been  mistaken  for  a 
cancerous  growth. 

Tumours   formed  of  coils  of  bowel  matted  together  by 

a  local  peritonitis  have  been  mistaken  for  masses  of  cancer. 

Mr.  Henry  Morris  has  reported  two  cases,  one  of  cancer 


SYMI'TOMS.  417 

of  the  ascending  colon  and  one  of  cancer  of  the  descending 
colon,  in  which  the  tumour  was  mistaken  for  a  movable 
kidney.  * 

In  certain  conditions  the  sigmoid  flexure  can  be  felt 
in  the  left  iliac  fossa  as  a  hard,  defined,  rounded  cord  ot 
varying  length,  and  pf  about  the  diameter  and  substance 
of  a  large  adult  thumb.  Such  a  segment  of  the  gut  has 
been  mistaken  for  a  cancerous  tumour. 

This  condition  of  the  sigmoid  flexure  is  due  to  a  thicken- 
ing of  the  bowel  and  a  contraction  of  its  muscular  walls. 
it  vanishes  or  becomes  less  under  an  anaesthetic.  This 
curious  contraction  may  be  met  with  in  any  form  of  colitis 
in  which  the  sigmoid  flexure  is  involved.  It  would  seem  as 
if  the  gut  is — owing  to  its  being  inflamed- — in  a  state  of 
irritability  which  presents  itself  under  the  form  of  an  abiding 
contraction. 

There  is  often  constipation  alternating  with  diarrhoea. 
The  bowel  appears  to  resent  the  entrance  of  fcecal  matter 
into  its  tender  and  sensitive  lumen,  and  such  matters  as 
do  enter  are  rapidly  expelled  with  discomfort  and  often 
with  tenesmus.  The  contracted  bowel  is  usually  tender,  and 
seems  to  contract  more  if  much  handled.  The  patient  often 
complains  of  a  tender  and  painful  spot  in  the  left  iliac 
fossa.  I  have  found  this  condition  in  quite  mild  degrees 
of  catarrh  of  the  sigmoid  flexure,  and  the  constipation  with 
which  it  is  associated  is  often  relieved  by  opium.  Leube 
calls  this  condition  of  the  bowel  sigmoiditis  chronica. 

A  stricture  in  the  sigmoid  flexure  or  even  in  the  lower 
part  of  the  descending  colon  has  been  felt  by  the  finger 
when  the  entire  hand  is  introduced  into  the  rectum.  Dr. 
Sands,  however,  reports  a  case  Avhere  a  stricture  situated 
within  fifteen  inches  of  the  anus  was  not  recognised,  although 
the  entire  hand  had  been  introduced  as  far  as  the  sigmoid 
flexure,  t 

III.    CHRONIC    INTUSSUSCEPTION. 

B}^  an  arbitrary  division  those  cases  of  intussusception 
are  considered  to  be  chronic  which  have  lasted  for  more 
than  one  month. 

Details  as  to  frequency  of  occurrence,  sex,  age,  and 
mode  of  onset  have  already  been  given  (page  849);  and  in  the 
account  of  the  acute  forms  a  general  notice  has  been  taken 
of  the  symptoms  of  invagination  (page  351). 

*  Lancet,  April  27,  189-5. 

f  Neiv  York  Med.  Jour//.,  vol.  xix.,  1874,  p.  622. 
B  P. 


il8  CimONiC    INTUSSUSCEPTION. 

It  remains  only  now  to  enter  into  certain  special  points. 

The  anatomical  form  of  intussusception  that  is  most 
often  met  with  in  chronic  cases  is  the  ileo-csecal.  It  forms 
more  than  one-half  of  all  the  examples.  The  enteric  form 
is  the  variety  that  is  the  least  often  chronic.  The  relative 
proportion  is  thus  given  by  Rafinesque ;  his  conclusions 
being  based  upon  a  collection  of  iifty-five  distinctly  chronic 
cases : — 

Ilen-cfecal 60  per  cent. 

Colic 15        „ 

Enteric    .......  15        „ 

Ileocolic 10        „ 

100 

To  appreciate  the  full  value  of  this  table  it  should  be 
compared  with  that  on  page  145,  which  deals  with  intussus- 
ceptions of  all  kinds  both  acute  and  chronic. 

The  clinical  features  of  chronic  intussusception  are 
often,  and  indeed  usually,  very  ambiguous.  No  form  of 
intestinal  obstruction  presents  so  many  confusing  elements 
in  the  diagnosis ;  no  form  has  led  to  more  conspicu  us 
errors  in  the  right  appreciation  of  the  nature  of  the  malady. 

Out  of  the  fifty-five  cases  collected  by  Rafinesque  many 
were  never  suspected  to  be  examples  of  intussusception,  and 
no  less  than  twenty-seven  were  the  subjects  of  an  absolutely 
incorrect  diagnosis.  Chronic  intussusception  has  been  mis- 
taken for  fsecal  accumulation,  for  rectal  polyp,  for  cancer 
of  the  bowel,  for  ulcer  of  the  stomach,  for  wandering  spleen,"^ 
for  dyspepsia,  for  chronic  dysentery,  for  gastro-enteritis, 
for  tuberculous  peritonitis,  and  for  other  ailments  equally 
remote  from  the  nature  of  the  actual  disease. 

The  course  of  the  malady  may  extend  over  man} 
months,  and  may  be  protracted  even  for  a  year.  In  one 
reported  instance  there  are  good  reasons  for  believing  that 
the  intussusception  had  existed  for  more  than  a  year.  Pohl 
has  recently  reported  a  case  of  intussusception  in  a  young 
man,  which  he  affirms  had  existed  for  no  less  than  eleven 
years.  The  invagination  involved  24  cm.  of  the  lower 
ileum,  and  the  lumen  of  the  gut  was  almost  obliterated. 
The  patient,  who  had  presented  intestinal  symptoms  during 
the  eleven  years,  died  of  an  acute  attack,  which  ended  on 
the  fifth  day  in  perforation,  t 

During  its  progress  the  malady  usually  follows  a  most 
irregular  course.     The  bowels  maybe  at  one  time  constipated, 

*  Clin.  Soc.  Trans.,  1898,  p.  227, 

t  Pragermed.  Wochenschr.,  No.  21,  1883. 


SYMrTOMS.  419 

and  at  another  in  a  state  of  diarrhoea.  There  may  be  violent 
pain  one  day  and  none  the  next.  Some  patients  are  troubled 
b}^  severe  vomiting,  while  others  are  never  sick.  In  some 
cases  there  are  long  intervals  of  freedom  from  sickness,  while 
in  others  there  are  no  such  breaks.  There  is  no  method  in 
the  irregularity  and  but  few  common  features  that  underlie 
all  the  cases  and  that  may  serve  as  certain  signs. 

The  onset  of  the  malady  is  usuall}^  a  little  indefinite,  and 
the  earliest  symptoms  are  often  ascribed  to  indigestion,  to 
mild  colic,  or  to  simple  irregularities  in  the  bowels.  In  about 
30  per  cent,  the  commencement  has  been  abrupt,  the  case 
subsequently  assuming  a  chronic  aspect.  In  any  case  pain  is 
usually  the  first  symptom.  The  ileo-colic  form  of  chronic 
invagination  usually  begins  suddenly. 

The  pain  that  occurs  during  the  progress  of  the  disease  is 
paroxysmal.  Attacks  of  pain  may  appear  several  times  a 
day  or  only  once  in  the  twenty-four  hours.  Sometimes  days, 
and  even  weeks,  have  elapsed  between  the  paroxysms.  The 
intervals  between  the  attacks  are  seldom  regular,  and  when 
the  pain  does  appear  at  stated  times  the  occurrence  is 
probably  due  each  time  to  a  repetition  of  the  same  cause ;  as, 
for  example,  when  the  paroxysm  has  usually  appeared  at 
night  after  a  late  supper. 

As  the  malady  advances  the  intervals  between  the  attacks 
of  pain  grow  shorter  and  the  pain  itself  becomes  more  diffused. 
In  the  less  protracted  cases  there  may  be  almost  continuous 
suffering,  marked,  however,  by  exacerbations. 

The  pain,  when  present,  has  the  general  character  de- 
scribed when  dealing  with  the  acute  form  of  the  disease 
(page  351). 

Vomiting  is  not  a  very  conspicuous  symptom.  In  forty 
of  Ratinesque's  cases  where  this  symptom  is  mentioned,  it 
occurred  more  or  less  frequently  in  twenty-four  instances. 
In  four  instances  the  patient  was  sick  at  rare  intervals,  in 
seven  vomiting  did  not  appear  until  within  a  few  days  or 
hours  of  death,  and  in  three  cases  there  was  an  entire 
absence  of  vomiting  throughout  the  progress  of  the  malady. 
In  any  case  the  attacks  of  sickness  were  very  rarely  con- 
tinuous. Usually  they  appeared  at  irregular  intervals  coin- 
ciding with  the  attacks  of  pain  or  depending  upon  some 
alimentary  excess. 

The  duration  of  the  affection  appears  to  have  little  effect 
upon  this  symptom.  Age  has  some  influence,  since  nearly  all 
the  cases  where  the  vomiting  was  insignificant  or  absent 
occurred  in  adults.  Vomiting  is  most  constant  in  the  ileo- 
colic and  enteric  forms,  and  usually  appears  earlier  in  those 


420  CHBOmC    INTUSSUSCEPTION. 

varieties  of  the  disease  than  it  does  in  the  other  forms. 
Stercoraceous  vomiting  is  met  with  in  less  than  7  per  cent,  of 
the  cases.  It  depends  rather  upon  the  degree  of  obstruction 
in  the  intestine  than  upon  the  seat  or  duration  of  the  in- 
testinal lesion. 

The  state  of  the  bowels  is  most  variable.  Natural  and 
regular  stools  may  be  passed  during  the  greater  part  of  the 
disease,  or  there  may  be  long-continued  diarrhoea,  or  marked 
constipation,  or  alternations  between  the  two  last-named 
conditions.  Indeed,  the  only  certain  feature  in  the  state  of 
the  bowels  in  chronic  invagination  is  the  feature  of  un- 
certainty. On  the  whole,  a  tendency  to  diarrhoea  is  the 
most  common  condition,  and  a  normal  state  of  the  bowels 
the  most  rare.  From  an  examination  of  forty-six  cases 
Rafinesque  obtained  the  following  results :  Motions  normal 
or  nearly  so,  seven  cases;  alternations  of  constipation  with 
diarrhoea,  eleven  cases ;  predominance  of  constipation,  twelve 
cases ;  and  predominance  of  diarrh<jea,  sixteen  cases.  Consti- 
pation is  most  marked  in  the  enteric  forms,  diarrhoea  in  the 
ileo-csecal,  and  alternations  between  these  two  conditions  in 
the  colic  and  rectal  varieties. 

Blood  is  passed  with  the  stools  in  about  50  per  cent, 
of  the  cases,  while  tenesmus  is  present  in  13  per  cent. 

In  chronic  invagination  the  bowels  usually  respond  to 
the  action  of  aperients.  These  drugs  sometimes  give  much 
relief,  but  more  often  provoke  at  least  a  temporary  aggrava- 
tion of  the  symptoms. 

In  any  case  of  long-standing  intussusception  a  certain 
degree  of  persisting  obstruction  must  exist  in  the  intestine. 
As  a  result  of  this,  the  bowel  above  the  invagination  becomes 
hypertrophied  by  excessive  development  of  its  muscular  Avail. 
The  patients,  on  the  other  hand,  usually  emaciate,  and  the 
anterior  abdominal  parietes  of  course  share  in  the  general 
wasting.  Thus  it  happens  that  coils  of  intestine  are  very 
often  to  be  seen  in  movement  beneath  the  belly  wall,  a 
circumstance  which  will  be  most  distinct  when  vigorous  and 
irregular  peristaltic  waves  are  passing  along  the  disordered 
intestine.  There  are  few  forms  of  chronic  obstruction  where 
this  feature  is  more  marked  than  it  is  in  the  present  class 
of  cases,  and  it  serves  as  a  valuable  factor  in  the  diagnosis. 
The  subject  of  visible  intestinal  coils  in  movement  and  of 
the  gurgling  and  bubbling  sounds  Avhich  attend  this  condi- 
tion is  dealt  with  on  page  304. 

The  general  condition  of  the  patients  in  chronic  invagi- 
nation shows,  as  may  be  imagined,  considerable  variation. 
In   the   early   periods   of  the  disease,  and  in   the   intervals 


SYMPTOMS.  421 

between  attacks  of  pain,  they  may  appear  to  be  in  fair 
health.  In  time,  however,  they  usually  become  anaemic 
and  emaciated.  They  are  worn  out  by  the  frequent  pain, 
and  exhausted  by  the  vomiting  and  diarrhoea. 

The  appetite  usually  becomes  much  impaired,  and  the 
symptoms  are  often  aggravated  by  food.  In  a  large  number 
of  instances  it  showed  considerable  fluctuations,  and  in  at 
least  one  case  it  was  voracious.'^ 

AVith  regard  to  the  state  of  the  abdomen,  little  can 
be  added  to  what  has  been  said  when  speaking  of  the 
acute  form  of  the  malady.  As  a  rule  the  abdominal  walls 
remain  llaccid  and  present  no  abnormal  feature.  When  a 
long-continued  diarrhcea  exists  with  emaciation  they  may 
be  retracted.  When  marked  constipation  exists  there  may 
be  some  meteorism,  which  will,  however,  always  be  moderate. 
Tenderness  on  pressure  is  very  seldom  to  be  noticed  except 
in  cases  which  are  associated  with  peritonitis. 

As  already  stated,  a  tumour  is  to  be  found  in  about 
one-half  of  the  cases.  Its  characters  have  been  fully  de- 
scribed above  (page  358).  The  tumour  may  vary  in  position 
and  consistence  from  day  to  day  and  even  from  hour  to 
hour. 

Among  the  tifty-five  cases  collected  by  Rafinesque,  the 
tumour  was  felt  in  the  rectum  in  seven  instances,  and  had 
protruded  beyond  the  sphincter  in  nine.  Thus  it  will  be 
seen  that  in  chronic  cases  the  invaginated  mass  reaches 
the  rectum  in  about  32  per  cent,  of  the  cases. 

In  Rafinesque's  series  the  mass  was  discovered  in  the 
rectum  on  about  the  fifteenth  day  in  three  instances,  and 
at  the  third,  fourth,  fifth,  and  seventh  month  respectively 
in  the  remaining  four  examples. 

Dr.  Coleman  reports  a  case — in  a  boy  aged  eight — in 
which  the  symptoms  had  existed  for  eighteen  weeks,  and 
in  which  a  tumour  could  be  felt  for  at  least  four  weeks 
before  operation. 

IV.    F.tCAL    ACCUMULATION. 

Clinical  Manifestations. — Obstruction  of  the  bowels  by 
fsecal  accumulation  is  more  common  in  females  than  in 
males,  is  most  frequently  met  with  in  those  who  have 
passed  middle  life,  and  is  very  common  in  the  subjects  of 
hysteria  and  hypochondriasis. 

It  is  common  to  find  a  history  of  dyspepsia,  of  imperfect 
teeth,  of  hurried  ur  irregular  meals,  and  of  long-continued 

*  Path.  Soc.  Trans.,  vol.  x.,  p.  160  :  Dr.  Qnain. 


422  F2EGAL    ACCUMULATION. 

neglect  of  the  bowels.  Some  patients  date  their  constipation 
from  some  long  illness.  Many  present  the  phenomena  of 
the  '-'neurotic." 

The  patients  are  liable  to  habitual  and  troublesome 
constipation.  Their  bowels  are  seldom  opened  without  the 
aid  of  aperients  or  enemata.  Many  days  may  elapse  without 
a  stool,  normal  in  amount,  being  passed,  and  from  time  to 
time  enormous  quantities  of  fiecal  matter  will  be  evacuated 
by  artificial  aid.  Sometimes  there  is  a  brief  interlude  of 
so-called  diarrhoea.  This  diarrhoea  is  wholly  spurious.  It 
depends  upon  catarrh  excited  in  the  bowel  above  the  fsecal 
accumulation.  The  catarrh  causes  a  free  exudation  to  be 
poured  into  the  intestinal  canal,  this  dissolves  a  certain 
amount  of  fsecal  matter,  which,  finding  its  way  beyond  the 
main  mass,  appears  at  the  anus  as  a  slight  watery  motion. 
{See  page  393.) 

In  such  cases  an  examination  of  the  rectum  may  reveal 
the  fact  that  that  gut  is  blocked  by  fsecal  matter. 

These  symptoms  of  troublesome  constipation  may  exist 
for  years  without  causing  more  than  a  little  rtialaise  or  a 
little  digestive  disturbance,  and  at  no  time  may  severer 
abdominal  disturbances  arise. 

In  more  marked  cases  the  abdomen  becomes  distended, 
evacuations  are  less  frequent  and  more  difficult  to  obtain. 
The  patient  complains  of  a  sense  of  fulness  and  weight  in 
the  abdomen.  His  appetite  is  poor,  his  tongue  is  very  foul, 
his  breath  most  offensive.  He  is  much  troubled  by  indi- 
gestion, by  distension  after  food,  by  flatulency,  and  by 
eructations,  etc.  There  is  a  foul  taste  in  the  mouth.  He 
not  infrequently  becomes  much  weakened  and  loses  flesh. 
He  may  become  lethargic  and  morose,  or  fretful,  irritable, 
and  uneasy,  and  present  some  phase  of  hj^pochondriasis. 

Some  patients  in  this  condition  complain  of  languor,  and 
are  disposed  to  sleep  a  great  deal.  Others  complain  of  head- 
ache and  vertigo,  and  possibly  of  dulness  of  intellect.  Two 
cases — both  in  women  past  middle  age— have  come  under 
my  notice  in  Avhich  the  patient,  after  suffering  from  complete 
constipation  for  some  weeks,  became  delirious  and  ultimately 
insane.  In  each  instance  the  patient  was  removed  to  an 
asylum,  and  the  complete  evacuation  of  the  bowels  by 
enemata  was  followed  by  a  speedy  recovery  of  the  mental 
condition. 

In  these  examples  of  marked  and  long- continued  con- 
stipation the  patient  is  apt  to  look  ill  and  to  present  some 
of  the  phenomena  of  intestinal  self-jioisoning.  The  skin  is 
often  dull,  greasy,  and  unwholesome-looking,  and  gives  out 


SYi£PTOMS.  4-23 

a  distinctly  unpleasant  odour.  The  conjunctivae  are  often 
yellow,  a  symptom  due  to  the  absorption  from  the  bowel  of 
certain  chromogens  which  are  the  products  of  decomposition. 
Other  symptoms  may  appear,  conspicuous  among  which  are 
fever,  rtialai^e,  headache,  some  delirium,  and  very  usually 
vomiting.  The  rise  of  temperature  noticed  so  often  in  these 
cases  is  no  doubt  due  to  septic  absorption  from  the  bowel,  and 
I  have  especially  noticed  that  the  rise  of  temperature  is  most 
common  after  the  fsecal  mass  has  been  disturbed.  Thus  some 
fever  is  quite  common  atter  the  dislodgment  of  a  quantity  of 
retained  fasces  by  enemata  or  other  means.  It  is  possible  that 
the  phenomena,  depending  on  absorption  of  decomposition 
products  from  the  bowel,  may  go  beyond  this.  Middleton"^ 
describes  a  case  of  ftecal  accumulation  in  which  the  symptoms 
which  preceded  death  were  persistent  vomiting,  high  tempera- 
ture accompanied  by  delirium,  and  inflammation  of  the 
parotid.  The  autopsy  revealed  a  large  collection  of  hard 
f'tecal  matter  in  the  colon,  but  no  mechanical  or  organic 
obstruction  in  any  part  of  the  bowel. 

If  the  abdomen  become  greatly  distended  other  symptoms 
may  appear.  There  may  be  palpitation,  a  sense  of  oppression 
in  the  chest,  and  a  little  dyspnoea  from  a  pressing  up  of  the 
diaphragm  by  the  distended  bowels.  Pressure  may  be  exer- 
cised upon  the  lumbar  or  sacral  nerves,  and  the  patient  may 
complain  of  discomfort  in  the  genitals,  of  nocturnal  emissions 
or  nocturnal  enuresis,  or  of  pain  in  the  thigh  (genito-crural 
nerves),  or  down  the  leg  along  some  part  or  parts  of  the  great 
sciatic  nerve.  Sciatica  is  not  uncommon  in  cases  of  fcfical 
accumulation. 

Or  injurious  pressure  may  be  exercised  upon  certain  veins: 
upon  the  spermatic  veins  ;  upon  the  pelvic  veins,  causing 
piles,  catarrh,  or  hypersemia  of  the  uterus,  or  menstrual 
irregularities  ;  upon  the  iliac  veins,  producing  uncomfortably 
cold  feet  or  even  oedema  of  the  extremities.! 

The  constipation  may  remain  absolute  for  weeks  and 
months.  All  the  symptoms  may  become  worse.  The 
abdomen  may  become  enormously  distended,  the  apex  of  the 
heart  may  be  pushed  up  to  the  third  intercostal  space^J  the 
distended  coils  may  be  visible  through  the  thinned  parietes, 
and  there  may  be  much  rumbling  and  gurgling  heard  in  the 
abdomen.  Visible  coils  in  movement  are  only  seen  when 
there  has  been  a  long-continued  block.  This  symptom  is 
never  so  marked  as  it  is  in  cases  of  strictiu-e,  and  is  often 

*   Glangotv  Med.  Jourii.,  1891,  p.  o-i'i. 

t  See  cHfic,  rath.  Soc.  Tiftn^;.,  vol.'xxiii.,  p.  101. 

J  Piith.  iSoc.  Tnins.,  vol.  iii.,  p.  106. 


424  FAlCAL    ACCUMULATION'. 

absent  even  in  severe  cases.  When  in  this  condition  the 
patient  has  most  probably  lost  his  appetite,  he  is  troubled 
with  i'requent  and  foul  eructations,  he  is  greatly  distressed  by 
the  distension  of  the  abdomen,  he  suffers  from  nausea  and 
ultimately  I'rom  vomiting.  This  vomiting  may  become 
stercoraceous.  The  abdomen  is  the  seat  of  more  or  less 
constant  colic,  which  is,  however,  as  a  rule  not  intense.  But 
even  when  the  symptoms  have  advanced  to  an  extreme  degree 
relief  may  be  afforded  either  by  enemata  or  by  a  spontaneous 
evacuation,  and  after  the  bowel  has  been  emptied  recovery 
may  follow.  On  the  other  hand,  the  case  progresses  from  bad 
to  worse,  the  patient  begins  to  experience  more  pain  in  the 
abdomen,  or  an  increase  in  the  comparatively  slight  pain  that 
may  have  existed  for  some  time,  he  develops  all  the  symptoms 
of  an  unyielding  obstruction,  of  which  he  dies,  unless  he 
succumb  to  the  effect  of  intestinal  septicaemia. 

In  several  cases  there  has  been  complete  constipation  foi 
two  or  three  months,  and  the  patient  at  the  end  of  that  time 
has  had  a  relief  of  the  bowels  and  has  rapidly  recovered.  Mr. 
Pollock  reports  the  case  of  a  lady,  aged  thirty-five,  who  only 
had  one  evacuation  of  the  bowels  every  three  months — that  is 
to  say,  four  evacuations  in  the  year.*  Dr.  John  Blake  reports 
the  case  of  a  man,  aged  forty-six,  whose  bowels  were  confined 
absolutely  for  eighteen  weeks.  At  the  end  of  that  time  he 
passed  a  motion  spontaneously,  but  died  within  a  few  days. 
Not  the  least  interesting  fact  in  this  case  is  the  circumstance 
that  an  aspirator- trochar  was  introduced  into  the  abdomen  of 
this  unfortunate  person  no  less  than  150  times  during  the 
continuance  of  the  constipation.  Before  the  conclusion  of 
the  case  the  patient  was  taking  twelve  grains  of  morphia  a 
day.f  In  another  case  a  man,  aged  twenty-six,  who  had  been 
always  liable  to  constipation,  had  at  one  time  no  evacuation 
of  any  kind  from  the  Dowels  ior  the  almost  incredible  period 
of  eight  months  and  sixteen  days.X  Dr.  Thomas  Strong,  who 
reports  this  case  with  considerable  detail,  alludes  to  instances 
of  patients  who  suffered  from  absolute  constipation  for  periods 
respectively  of  seventy-six  days,§  fifteen  weeks, ||  seven 
months,^  eight  months,"^*  and  nine  nrionths.tt 

*  Holmes's  System  of  Surgery,  vol.  ii.,  p.  725,  3rd  ed. 
f  Boston  Med.  and  Sure/.  Journ.,  vol.  xv.,  Nov.,  1876,  p.  601. 
t  Amer.  Journ  of  Med.  Sc,  vol.  Ixviii.,  1874,  p.  440. 
^  North  Amer.  Med.  and  Surg.  Journ.,  vol.  iv.,  p.  262. 

II  Dr.  iJaillie,  Trans,  of  a  Soc.  for  the  Promoting  of  Med.  and  Chir.  Know- 
ledge, vol.  ii.,  p.  174. 

^   Staniland;  Lond.  Med.  Gazette^  vol.  xi.,  p.  245. 

**  Dr.  Crampton;  Dublin  Hosp.  Reports,  vol.  iv.,  p.  303. 

ft  Dr.  Valentino;  Bull,  dcs  Sc.  Med.,  tomo  x.,  p.  74. 


SYMPTOMH.  425 

In  another  and  connuon  class  of  cases  the  patient  is  hable 
from  time  to  time  to  what  may  be  termed  obstructive  attacks. 
I  have  known  three  such  attacks  to  take  place  within 
twelve  months,  the  bowels  having  been  well  cleared  out  after 
each  attack.  In  these  attacks  it  is  probable  that  the  much 
narrowed  canal  becomes  more  or  less  suddenly  blocked, 
whereas  in  the  previous  class  of  cases  the  occlusion  is  brought 
about  by  very  gradual  processes.  The  more  abrupt  stoppage 
may  be  due  to  the  dislodgment  of  a  hard  mass  of  fseces  ;  or  it 
may  depend  upon  bending  or  kinking  of  the  distended  bowel. 
The  latter  condition  may  be  met  with  in  the  transverse  colon 
and  in  the  sigmoid  flexure,  and  especially  at  the  point  of 
junction  of  the  flexure  with  the  rectum.  In  a  few  cases  a 
volvulus  of  moderate  degree  seems  to  have  formed. 

A  patient,  therefore,  who  has  presented  for  months  the 
symptoms  of  chronic  constipation,  may  be  more  or  less 
suddenly  attacked  with  severe  colicky  pains  in  the  abdomen. 
Associated  with  this  symptom  are  absolute  constipation, 
increased  distension  of  the  abdomen,  and  very  probably 
tenesmus.  The  patient  is  troubled  by  nausea  and  foul 
eructations,  and  soon  begins  to  vomit.  The  vomiting  is  not 
so  easily  established  as  it  is  in  some  of  the  other  of  the  less 
chronic  varieties  of  obstruction,  nor  is  it  usually  severe.  It 
may,  however,  become  stercoraceous,  but  this  is  rare.  All  the 
symptoms  are  commonly  aggravated  by  taking  food.  Coils  of 
intestine  may  occasionally  be  visible,  and  more  or  less 
constant  borborygmi  will  be  heard  in  the  abdomen.  The 
symptoms  may  become  worse  and  worse,  and  the  patient  may 
finally  die  of  exhaustion  and  intestinal  septicaemia. 

Before  death  he  may  or  may  not  have  developed  evidences 
of  peritonitis. 

The  first  of  these  attacks  may  prove  fatal ;  but  such  an 
occurrence  is  very  rare.  As  a  rule,  the  patient  has  many 
obstructive  attacks,  which  probably  increase  in  severity  as 
time  advances.  These  attacks  may  last  from  three  and  four  to 
ten  and  fifteen  days,  may  be  associated  with  stercoraceous 
vomiting,  and  may  be  at  last  relieved  either  spontaneously  or 
by  the  use  of  aperients  and  enemata.  An  enema,  whether  it 
at  once  produce  an  evacuation  or  not,  is  often  followed  by  an 
improvement  in  the  symptoms  for  a  while. 

In  all  cases  of  obstruction  by  ftecal  masses,  no  matter 
what  may  be  their  particular  clinical  aspect,  there  is  very 
usually  present  a  diagnostic  feature  of  much  importance  to 
which  allusion  has  not  yet  been  made.  I  refer  to  a  tumour 
formed  by  the  niasf^  of  retained  fceces. 

This  tumour  is,  as  a  rule,  most  readily  to  be  felt  in  the 


426  FJEGAL    ACCUMULATION. 

caecum.  The  caecum,  it  is  needless  to  say,  occupies  the  right 
iliac  fossa  in  such  a  way  that  its  extremity  usually  reaches 
nearly  to  the  middle  of  Poupart's  ligament.  The  faecal  mass, 
therefore,  will  correspond  to  the  outer  half  of  the  ligament. 
Such  tumours  feel  hard  and  uneven,  are  of  a  globular  shape, 
and  are,  as  a  rule,  painless.  Sometimes,  however,  the  tumour 
is  the  seat  of  much  tenderness,  a  circumstance  that  probably 
depends  upon  some  ulceration  of  the  bowel  (stercoral  ulcer). 
In  the  ascending  colon  the  tumour  will  possibly  feel  softer, 
will  be  cylindrical  in  outline  and  very  like  a  chronic  in- 
tussusception, especially  as  its  limits  cannot  be  usually  well 
defined  (Fig.  115). 

Masses  in  the  transverse  colon  may,  when  near  the 
hepatic  Hexure,  give  rise  to  the  impression  that  the  liver 
is  enlarged,  the  extent  of  dulness  over  that  viscus  being 
increased.  These  tumours,  when  in  a  mobile  part  of  the 
colon,  are  of  course  themselves  movable.  Masses  in  the 
transverse  colon  may  cause  the  gut  to  become  bent  down, 
and  the  faecal  tumour  therefore  has  in  such  castas  been  felt 
near  to  the  symphysis.  When  in  the  descending  colon  or 
sigmoid  flexure  the  faecal  mass  will  usually  feel  harder  and 
its  division  into  scybala  may  be  detected.  Some  of 
these  lumps  are  of  stony  hardness.  Indeed,  tumours 
in  this  situation  have  been  compared  to  a  large  rosary 
on  account  of  their  uneven  and  nodular  surface  and  their 
density. 

In  thin  individuals  and  in  others,  when  under  an  anaes- 
thetic, the  softer  of  these  faecal  masses  may  be  affected  by 
pressure  and  may  give  to  the  fingers  the  reaction  of  a  mass 
of  dough  or  of  putty.  When  such  a  character  is  presented 
by  the  tumour  the  diagnosis  of  its  nature  is  placed  beyond 
doubt.  This  feature  in  the  faecal  mass  is,  however,  quite  un- 
common. I  have  encountered  it  most  often  when  I  have 
felt  a  loaded  sigmoid  flexure  through  the  rectal  wall. 

Ysecsd  tumours  may  exist  unchanged  for  weeks  or  months, 
and  may  coincide  with  the  passage  ot  normal  motions  or  with 
the  spurious  diai'rhoea  to  which  attention  has  already  been 
directed. 

These  tumours  have  been  mistaken  for  cancer,  for  chronic 
intussusception,  for  tumours  of  the  liver,  stomach,  spleen,  and 
kidneys,  for  ovarian  and  other  pelvic  tumours,  for  sarcoma  of 
the  omentum,  for  retroperitoneal  sarcoma,  for  tuberculous 
glands,  and  for  pregnancy.  The  great  distension  of  the 
abdomen  and  the  presence  of  much  flatus  within  the  in- 
testine in  these  cases  are  apt  to  obscure  the  details  of  the 
mass  when  it  exists. 


SYMPTOMS. 


427 


Dr.  Worrall"^  reports  the  case  of  a  girl  of  thirteen  upon 
whom  laparotomy  was  performed  for  a  rapidly  increasing 
abdominal  tumour.  It  proved  to  be  a  colon  loaded  with 
faeces. 

In  a  case  of  obstruction  from  impacted  freces  brought 
before  the  notice  of  the  Sheffield  Medico-Chirurgical  Society 
by  Dr.  Thomas,  it  is  stated  that  after  aperients  had  been 
administered  and  massage  applied, 
"  the  sound  of  the  moving  faeces  was 
heard  with  the  stethoscope."  This 
experience  is,  so  far  as  I  am  aware, 
unique.     It  is  certainl}^  remarkable. 

Dr.  Gersunyt  mentions  the  fol- 
lowing as  a  feature  of  the  fsecal 
tumour.  If  the  tumour  be  firmly 
pressed  with  the  finger  the  intestinal 
mucous  membrane  is  made  to  adhere 
to  the  ftecal  mass.  When  the  pres- 
sure is  removed  the  mucous  mem- 
brane frees  itself,  and  the  act  of  its 
withdrawing  itself  from  the  solid 
mass  is,  according  to  Gersuny,  capable 
of  being  appreciated.  He  illustrates 
the  sensation  conveyed  by  the  press- 
ing of  an  oiled  finger  into  the  palm 
of  the  hand  and  the  slow  withdrawal 
of  it  from  such  contact. 

I  cannot  say  that  I  have  been 
able  to  appreciate  this  phenomenon 
up  to  the  present  time.  When  gas 
colon  containing  a  fsecal  tumour  I 
that  the  bowel  wall  has  been  removed  from  the  mass  which 
I  have  been  examining  with  my  fingers,  but  such  an 
experience  is  uncommon  and  is  seldom  convincing. 

As  much  importance  attaches  to  the  appreciation  of  a 
fiscal  mass,  a  word  may  be  said  as  to  the  examination  of  the 
abdomen  when  such  a  tumour  is  suspected. 

The  patient  must  lie  upon  the  back  with  the  shoulders 
raised  and  the  knees  bent.  The  mouth  should  be  open  and 
the  patient  be  told  to  take  several  very  deep  breaths,  in  order 
to  get  the  abdominal  muscles  lax.  The  surgeon's  hand 
should  be  warm,  and  should  be  laid  gently  upon  the  ab- 
domen. The  examination  nuist  be  made  with  the  whole  row 
at  once.     They  must  be  gradually  pressed  deeper 


Fig 


115. ^Diagram  showing 
the  positions  in  which  faecal 
masses  are  common. 


has   passed   along   a 
have    become    aware 


of  lingers 


*  Kew  York  Med.  Record,  1888,  p.  723. 
t  Wion  klin.  Woch.,  Oct.  1,  189G. 


428  F.f.CAL    ACCUMULATION. 

and  deeper,  and  must  be  continually  moved  to  and  fro. 
The  abdominal  muscles  soon  become  accustomed  to  the 
pressure  and  cease  to  resent  it. 

The  caecum  is  easily  examined.  In  examining  the  ascend- 
ing or  descending  colon  the  left  hand  must  be  placed  in  the 
corresponding  loin  and  be  made  to  push  the  tissues  forwards 
towards  the  right  hand,  which  is  placed  on  the  abdomen. 
The  segment  of  the  colon  is  thus  brought  between  the  two 
hands.  In  examining  the  two  flexures  the  patient  must  be 
made  repeatedly  to  draw  a  deep  breath. 

The  patient  should  be  turned  upon  tirst  one  and  then  the 
other  side,  while  the  loin,  which  is  uppermost,  and  the  de- 
pendent part  of  the  belly,  which  is  lowermost,  are  being 
examined. 

The  abdomen  should  also  be  well  manipulated  while  the 
patient  is  on  his  hands  and  knees.  In  this  attitude  an 
examination  proves  often  to  be  of  the  greatest  service. 

A  thorough  digital  exploration  of  the  rectum  is  most 
essential. 

The  mass  when  discovered  will  be  found  to  have  the 
degree  of  mobility  which  is  to  be  expected  in  the  particular 
segment  of  bowel  occupied.     This  mobility  is  not  very  great. 

It  is  most  desirable  to  take  the  utmost  pains  to  satisfy 
oneself  that  the  mass  is  really  in  the  colon,  or  that  it  can 
reasonably  be  assumed  to  be  in  the  colon. 

The  tumour  is  practically  always  rounded  upon  its  pre- 
senting surface.  The  sarcomatous  growth  of  the  omentum, 
which  is  often  so  like  a  faical  mass,  is  quite  flat  on  that 
surface  which  is  in  contact  with  the  anterior  abdominal 
parietes.  The  growth,  moreover,  often  has  great  mobility, 
and  slips  out  of  the  way  on  a  mere  touch.  It  is,  more- 
over, seldom  tender,  whereas  the  fsecal  mass  is  very 
often  tender  on  handling.  Scybalous  lumps  when  in  the 
sigmoid  flexure  often  stand  out  with  quite  remarkable 
clearness. 

In  conclusion,  two  things  have  to  be  remembered.  In 
the  first  place,  any  one  of  the  conditions  which  have  been 
mistaken  for  a  faecal  mass  may  be  in  existence  at  the 
same  time  as  the  fsecal  tumour.  I  have  many  times  seen 
a  large  fsecal  mass  above  a  cancerous  stricture  of  the  colon. 
The  fseces  could  be  felt,  but  not  the  stricture.  I  have 
known  the  utmost  coniusion  in  diagnosis  to  arise  in  a  case 
in  which  a  dermoid  cyst  of  the  ovary  was  associated  with 
an  enormous  collection  of  Iteces  in  the  transverse  and 
ascending  colon. 

1  have  removed  gall  stones  li-om  a  gall  bladder,  in  front 


SYMPTOMS.  42J> 

of  which  was  a  large  mass  of  old  impacted  l«ces  which 
had  been  confidently  regarded  as  representing  the  fundus 
of  the  gall  bladder.  The  real  fundus  of  the  gall  bladder 
could  never  have  been  felt  in  the  case  in  question. 

In  the  second  place,  a  perfectly  astonishing  amount  of 
fsecal  matter  may  be  stowed  away  in  the  abdomen  without 
presenting  any  physical  signs  sufficient  to  attract  the  notice 
of  the  surgeon. 


430 


CHAPTER    VIII. 

THE  COURSE  AND  PPiOGNOSIS  IN  CHRONIC  INTESTINAL 
OBSTRUCTION. 

1.  Stenosis  of  the  Small  Intestine. — It  is  well  known 
that  a  non-malignant  stricture  ot  the  small  intestine  may 
exist  for  years,  or  probably  for  a  lifetime,  and  yet  cause 
no  symptoms,  provided  that  it  does  not  encroach  too  much 
upon  the  lumen  ot  the  bowel. 

The  present  section  is  only  concerned  with  such  cases 
of  stricture  of  the  bowel  as  are  so  narrow  as  to  produce 
definite  symptoms  of  intestinal  obstruction. 

The  duration  of  the  case  is  reckoned  from  the  onset 
of  obstructive  symptoms  to  the  termination  of  the  trouble 
by  operation  or  death. 

An  examination  of  recorded  cases  shows  that  the  average 
duration  of  examples  of  all  kinds,  both  simple  and  malignant, 
is  from  three  to  six  months. 

In  instances  in  which  the  stricture  has  become  suddenly 
blocked,  or  the  narrowed  bowel  kinked,  the  total  duration 
of  the  symptoms  has  been  as  short  as  eight  days.  These 
cases  have  been  acute,  and  the  obstructive  symptoms  have 
appeared  suddenly  in  patients  who  have  exhibited  no  bowel 
derangement.  In  another  series  of  examples  the  patient 
has — in  cases  of  non-malignant  stricture — continued  to 
present  obstructive  symptoms  for  as  long  a  period  as 
eighteen  to  twenty-four  months.  Such  a  course  has  been 
rendered  possible  by  the  most  carelul  treatment,  especially 
in  the  matter  ot  dieting. 

In  Kceberle's  case  (page  528)  the  symptoms  of  stricture 
had  existed  for  two  or  three  years  before  the  patient  was 
relieved  by  operation. 

The  prognosis  in  stricture  of  the  small  intestine  is  abso- 
lutel}'^  unfavourable  unless  the  case  be  relieved  by  operation  ; 


cnmsE  AND  rnoGNOSis.  431 

and  when  the  stricture  is  due  to  maUgnant  disease  an 
operation  can  only  be  expected  to  act  as  a  palUative  measure. 

Spontaneous  rehef  to  the  obstructed  part  may  be  given 
by  ulceration  of  the  bowel  above  the  stricture.  By  means 
ot"  such  ulceration  this  part  of  the  intestine  may  communi- 
cate with  the  bowel  below  the  seat  of  the  stenosis,  and 
through  this  communication  the  intestinal  contents  may  be 
passed  along.  Although  there  are  few  cases  where  continued 
relief  has  been  obtained  by  these  means,  yet  many  cases  show 
that  it  is  quite  possible.  As  examples  of  this  I  may  quote 
an  instance  of  stricture  of  the  ileo-crecal  valve  where  this 
method  of  spontaneous  cure  had  taken  place.  In  this 
instance  the  ileum  above  the  stricture  had  communicated 
with  the  colon  below  it."^ 

In  another  case  in  which  the  transverse  colon  was 
occluded  by  cancer,  a  communication  had  been  effected 
between  the  colon  and  the  ileum,  f 

It  is  possible  also  for  a  fsecal  fistula  to  form  above  the 
stenosed  part,  which,  by  a  communication  with  the  surface, 
plays  the  part  of  an  artificial  anus.  In  a  case  under  my 
care  at  the  London  Hospital  an  obstruction  existed  in  the 
small  intestine  due  to  a  matting  together  of  the  coils  of 
the  bowel.  The  mucous  membrane  had  become  the  seat 
of  tuberculous  ulcers,  one  of  which  had  led  to  perforation, 
and  subsequently  to  a  fsecal  fistula  discharging  near  the 
umbilicus.  Through  this  fistula  the  contents  of  the  bowel 
were  passed,  and  for  many  weeks  before  death  no  fsecal  matter 
was  passed  in  any  other  way  than  through  this  abnormal 
passage. 

In  stricture  of  the  small  intestine  death  is  due  to  many 
causes. 

Some  die  of  acute  obstruction  depending  upon  the 
blocking,  kinking,  or  twisting  of  the  stenosed  bowels. 

Others  die  of  exhaustion  or  succumb  to  the  remote 
effects  of  the  malignant  growth.  Peritonitis  and  intestinal 
septicaemia  mark  the  closing  scenes  in  many  instances. 
Death  has  been  ascribed  to  septic  pneumonia  and  to  heart 
failure. 

I  have  seen  a  case  in  which  death  was  due  to  the 
diarrhoea  which  is  an  occasional  feature  of  these  cases,  but 
which  in  this  instance  became  persistent,  acute,  and  uncon- 
trollable. 

2.  Stenosis  of  the  Colon. — What  has  been  said  about 
stricture   of   the   small  intestine  applies,   with  little   modifi- 

*  Path.  Soc.  Trans.,  1870,  p.  171. 

t  Ibid.,  1889,  p.  Ill ;   Dr.  Kayraond  Johnson's  case. 


4r{2  (JHIiOXIC    TNTESTIXAT.    OBSTBUCTIOX. 

cation,  to  the  like  trouble  in  the  colon.  The  duration  ol 
the  disease  dates  from  the  onset  of  symptoms  of  actual 
obstruction. 

The  average  duration  ot  the  s}TQptoms  in  stricture  of 
the  colon  is  from  three  to  nine  months.  This  includes  cases 
of  all  kinds.  In  a  few  instances  the  earlier  symptoms  are 
so  insigniticant  that  the  patient  has  made  no  complaint 
until  the  final  obstructive  attack  has  occurred.  Such  cases 
appear  to  artbrd  examples  of  stricture  which  are  fatal  in 
sixteen  days  or  even  less.  The  fallacy  in  such  cases  is 
obvious. 

On  the  other  hand,  it  may  be  said  that  the  duration 
of  life  in  cancer  of  the  colon  may  extend  from  six  months 
to  two  years.  In  this  estimate  it  is  assumed  that  an 
operation  has  been  performed  to  relieve  obstruction  symptoms 
when  they  occurred,  but  that  there  has  been  no  such  radical 
measure  carried  out  as  excision  of  the  affected  segment  of 
the  bowel. 

Death  is  due  to  many  causes.  The  majority  succumb 
to  the  direct  effects  of  intestinal  obstruction,  some  perish 
from  operations,  and  not  a  few  from  peritonitis  and  intes- 
tinal septicaemia. 

Perforation  of  the  bowel  above  the  stricture  is  not  un- 
common, and  in  some  cases  the  ulcerated  gut  in  this  position 
has  been  described  as  "giving  way''  or  as  being  "niptured." 
Some  patients  have  died  from  the  abscess  formed  about  the 
stricture,  such  a  focus  of  foul  suppuration  being  capable 
of  leading  to  death  in  many  ways. 

Among  other  and  less  common  causes  of  death  must  be 
placed  persistent  diarrhcea,  septic  pneumonia,  and  what  is 
vaguely  termed  heart  failure. 

The  prognosis  m  all  forms  of  stricture  of  the  colon  is 
entirely  bad  provided  that  the  stenosed  part  be  narrow 
enough  to  offer  a  definite  obstruction. 

The  only  prospect  of  spontaneous  relief  is  afforded  by 
ulceration  of  the  gut  above  the  stricture  and  the  subsequent 
formation  of  a  fistula  which  can  act  the  part  of  a  preternatural 
anus.  Thus  a  f^cal  abscess  may  form  in  the  subserous  con- 
nective tissue  and  be  eA'acuated  externally  either  by  nature  or 
art.*  Such  abscesses  are  comparatively  common :  I  have 
evacuated  them  in  both  the  csecal  region  and  in  the  loins. 
Or  the  intestine  above  the  obstruction  may  commimicate  with 
the  gut  below  it,  as  is  possible  in  a  case  of  stricture  in  the 
lower  part  of  the  sigmoid  flexiu'e,  where  the  flexure  is  much 
distended  and  freely  movable ;  or,  lastly,  the  fistulous  opening 

*  Dr.  Dickinson'.?  case;  Path.  Soc.  Trans.,  toI.  xxiii.,  p.  161. 


COURSE    AND    PROGNOSIS.  433 

may  discharge  itself  through  the  wall  of  the  bladder  or 
vagina.'^  Such  attempts  at  spontaneous  relief  are  efficacious 
only  for  a  little  while  and  the  changes  that,  attend  the  forma- 
tion of  the  fistula  usually  lead  to  such  further  destructive 
processes  as  are  incompatible  with  life. 

Moreover,  if  the  stricture  be  due  to  cancer,  as  it  usually  is 
in  such  cases,  the  course  of  events  is  not  materially  affected 
by  these  natural  attempts  at  relief. 

3.  Chronic  Intussusception. — The  prognosis  of  intussus- 
ception in  general  has  been  considered  on  page  379,  and  to 
this  section  the  reader  is  referred. 

It  only  need  be  said  here  that  chronic  intussusception 
is  a  very  fatal  malady.  Out  of  the  fifty-nine  examples  of 
chronic  intussusception  collected  by  Rafinesque  no  less  than 
fifty-one  died. 

The  course  of  chronic  intussusception  and  its  possible 
duration  have  been  already  alluded  to  (pages  351  and  380). 

As  to  the  modes  of  death,  some  die  of  an  acute  attack  that 
suddenly  appears  and  puts  an  end  to  tHe  case.  Others  die 
simply  of  exhaustion  and  marasmus.  A  few  succumb  to  per- 
forative peritonitis,  and  a  small  number  to  effects  depending 
upon  the  spontaneous  elimination  of  the  intussusceptum. 

4.  Faecal  Accumulation. — The  course  and  duration  of 
cases  of  obstruction  due  to  the  impaction  of  fa3ces  within  the 
bowel  have  already  been  fully  dealt  with  (page  423). 

With  regard  to  the  prognosis,  it  may  be  said  to  be  upon 
the  whole  good.  Theoretically  no  person  should  die  of  the 
mere  accumulation  of  faeces  in  the  bowel. 

The  condition,  when  it  exists,  should  be  capable  of  being 
relieved  by  treatment.  Probably  in  the  majority  of  cases  it  is 
successfully  relieved  by  treatment. 

Patients  may  present  the  symptoms  of  chronic  constipation 
through  the  greater  part  of  a  lifetime.  In  the  obstructive 
attaclvs  also,  no  matter  whether  of  gradual  or  of  abrupt 
development,  a  termination  by  relief  is  more  frequent  than  a 
termination  by  death.  At  the  same  time,  it  must  be  noted 
that  the  longer  the  morbid  condition  persists,  and  the  more 
frequent  the  attacks  of  ileus  become,  the  more  grave  is  the 
prosfnosis. 

The  causes  of  death  in  these  cases  are  numerous.  The 
patient  may  die  exhausted  by  prolonged  obstruction  with  its 
attendant  effects  upon  the  digestion  and  general  nutrition 
He  may  die  of  rupture  or  perforation  of  the  distended 
bowel. 

Of  this  accident  there  are  very  many  recorded  cases.     The 

*  Mr.  Simon's,  case;  Path.  Soc.  Trans.,  vol.  i.,  p.  264. 
C  C 


434  CHRONIC    INTESTINAL    0B8TEUGTI0N. 

part  of  the  bowel  which  has  most  usually  given  way  is  the 
caecum,  and  next  in  frequency  the  sigmoid  flexure. 

As  a  rule,  the  perforation  has  been  into  the  peritoneal 
cavity,  but  it  has,  in  rare  instances,  been  extra-peritoneal  and 
a  fgecal  abscess  has  resulted. 

In  a  few  cases  the  patient's  death  seems  to  have  been  due 
to  interference  with  the  action  of  the  heart  depending  upon  an 
enormous  distension  of  the  abdomen. 

In  not  a  few  examples  the  termination  of  the  case  has 
been  marked  by  the  symptoms  of  intestinal  septicaemia,  the 
patient  being  poisoned  by  the  products  of  decomposition 
absorbed  from  his  own  bowel. 

In  the  more  rapid  cases  death  may  be  due  to  acute 
obstruction  depending  upon  sudden  blocking  of  the  bowel,  or 
upon  acute  bending  or  kinking  of  the  elongated  intestine,  or 
upon  a  volvulus  of  the  distended  and  tortuous  sigmoid  flexure. 
The  dependence  of  volvulus  of  the  sigmoid  flexure  upon 
chronic  constipation  has  been  already  pointed  out  (page  128). 


435 


CHAPTER    IX. 

CHRONIC  INTESTINAL  OBSTRUCTION  ENDING  ACUTELY. 

There  is  not  one  of  the  many  forms  of  chronic  obstruction 
described  in  preceding  chapters  in  which  all  the  evidences 
of  acute  occlusion  may  not  abruptly  develop. 

If  the  acute  obstructive  attack  appear  while  the  case  is 
under  the  observation  of  the  surgeon  there  can  of  course  be 
no  difficulty  in  the  diagnosis.  If,  however,  the  patient  is 
seen  for  the  first  time  during  the  height  of  one  of  such 
attacks,  then  the  symptoms  may  be  very  readily  considered 
to  depend  upon  one  or  other  of  the  pathological  conditions  that 
lead  to  acute  strangulation.  Thus  the  abdomen  has  been 
opened  under  the  impression  that  a  coil  of  intestine  was 
strangulated  by  a  band,  and  the  primary  cause  of  the  occlu- 
sion found  to  be  a  stricture  of  the  bowel.  Laparotomy  has 
been  performed  for  what  was  supposed  to  be  a  subacute 
intussusception  and  nothing  discovered  beyond  a  mass  of 
malignant  disease  in  the  colon. 

It  might  be  said  at  once  that  there  is  no  one  special  form 
of  intestinal  obstruction  that  can  be  placed  in  this  class  and 
in  no  other.  There  is  no  form  of  chronic  obstruction  of  the 
bowels  which  invariably  leads  to  an  acute  attack. 

The  most  common  varieties  of  chronic  obstruction  are 
those  that  depend  upon  faBcal  accumulation  and  upon 
stricture  of  the  colon. 

In  fsecal  accumulation  symptoms  very  closely  resembling 
those  of  acute  intestinal  obstruction  may  appear  if  a  little 
peritonitis  arise  about  the  greatly  distended  and  perhaps 
nearly  perforated  bowel  There  will  be  suddenly  presented 
the  symptoms  of  intense  pain,  with  some  collapse,  with 
frequent  vomiting  and  with  absolute  constipation  and  marked 
distension  of  the  abdomen. 

Or  in  other  cases  the  bowel,  which  has  long  been  loaded, 


436        CHEONIG    OBSTBVGTIOX  EXDIXG   AGUTELY. 

may  become  absolutely  blocked  so  tbat  even  flatus  cannot 
pass ;  or  acute  symptoms  may  depend  upon  the  kinking  or  the 
abrupt  bending  or  the  twisting  of  the  greatly  elongated  and 
distended  colon. 

In  connection  with  strictures,  also,  the  case  may  proceed 
quietly  for  months,  the  stenosed  part  becoming  narrower  and 
narrower,  and  the  symptoms  more  and  more  clearly  defined. 
Suddenly  the  patient  develops  an  acute  attack  of  obstruction, 
and  if  death  results  the  gut  will  be  found  to  have  become 
sudclenty  occluded  at  the  narrowest  part.  This  occlusion 
may  be  due  to  kinking  or  to  acute  bending  of  the  bowel,  or 
to  blocking  of  the  stricture  b}'  some  foreign  substance,  or  by 
a  faecal  mass  or  a  mass  of  undigested  food.  If  the  stricture 
involve  the  upper  parts  of  the  rectum  then  the  distended 
sigmoid  flexure  above  the  stenosis  may  be  found  to  have 
become  twisted  upon  itself,  and  to  have  brought  about  the 
condition  of  volvulus. 

Unfortunately,  it  is  not  very  uncommon  for  the  pheno- 
mena of  acute  obstruction  to  appear  without  there  having 
been  any  noteworthy  symptoms  of  intestinal  trouble  ante- 
cedent to  the  acute  attack.  In  certain  of  these  cases  the 
acute  symptoms  appear  to  seize  a  patient  who  is  at  the 
time  of  the  occurrence  assumed  to  be  in  good  health. 

I  have  just  alluded  to  the  fact  that  a  little  peritonitis 
arising  in  a  case  in  which  there  is  some  chronic  obstruction 
of  the  bowel  may  precipitate  events  and  lead  to  quite  acute 
manifestations.  The  following  is  an  example  of  this:  A 
hale-looking  man  of  seventy  was  admitted  into  the  London 
Hospital  under  m}^  care  with  all  the  symptoms  of  acute 
intestinal  obstruction.  He  was  seized  with  violent  pain  in 
the  abdomen  while  at  his  work  two  days  before  admission. 
He  is  said  to  have  fainted  and  to  have  vomited  almost 
directly.  He  was  too  ill  to  walk  and  had  to  be  carried  home. 
The  pain  continued  and  increased,  and  the  vomiting  was 
frequent  and  very  distressing,  and  in  a  note,  sent  up  to  the 
hospital  with  the  patient,  the  doctor  who  had  seen  him 
before  admission  stated  that  the  vomited  matter  had  been 
fseculent.  There  had  been  no  rise  of  temperature.  The 
patient  was  seen  some  few  hours  after  admission  He  was 
a  well-developed  man,  and  was  evidenth'  very  ill.  His 
temperature  was  subnormal,  his  pain  had  been  subdued  by 
'  morphia ;  the  vomiting,  however,  continued,  the  amount 
ejected  was  small  and  the  odour  of  the  vomited  matter 
would  be  described  as  "  intestinal."  There  was  some  dis- 
tension of  the  abdomen  and  some  tenderness  of  it,  but  the 
latter  sym23tom    was   not  marked.      The   constipation  had 


CHRONIC    OBSTRUCTION  ENDING    ACUTELY.        437 

been  absolute  since  the  onset  of  the  symptoms  and  the 
enemata  given  had  been  returned. 

The  patient  was  actually  at  work  at  the  time  of  the  onset 
of  the  sympt(jms,  and  he  said  that  before  the  attack  his 
bowels  had  "  given  him  no  trouble." 

The  abdomen  was  opened  on  the  third  da)^  of  the  illness 
on  the  assumption  that  there  was  acute  strangulation  of 
the  bowel.  No  such  condition,  however,  was  found.  There 
was  a  cancerous  stricture  of  the  sigmoid  flexure.  Above  it 
there  had  evidently  been  some  extensive  ulceration,  for  at 
this  sjjot  there  were  manifestations  of  recent  peritonitis.  An 
artificial  anus  was  established. 

In  cases  of  stricture  of  the  bowel  in  which  distinct 
symptoms  of  chronic  obstruction  are  present,  acute  mani- 
festations may  follow  the  administration  of  a  smart  pur- 
gative. 

I  have  also  seen  a  case  m  which  acute  manifestations  appear 
to  have  followed  the  giving  of  morphia.  In  such  an  instance 
it  may  be  that  the  morphia  arrested  the  activity  of  the 
greatly  hypertrophied  and  ever-active  mtestine,  and  so  led 
to  some  condition  of  mechanical  blocking  which  would  be 
possible  with  loaded  coils  which  had  become  inert  and 
passive. 

In  the  less  common  forms  of  chronic  obstruction  Uke 
conditions  may  be  met  with.  Thus,  chronic  intussusception 
very  often  ends  in  an  acute  attack  which  may  prove  rapidly 
fatal.  Coils  of  intestine  matted  together  by  adhesions  may 
become  suddenly  occluded  by  bending  or  kinking,  at  one 
or  more  points,  and  so  lead  to  acute  manifestations,  xl  case 
of  partial  volvulus,  or  of  volvulus  associated  with  slight 
symptoms,  may,  as  a  result  of  distension  or  of  paralysis, 
become  at  any  moment  an  example  of  acute  volvulus 
with  appropriate  symptoms.  Any  portion  ot  the  bowel 
partially  occluded  by  compressing  adhesions  or  by  a  tumour 
outside  its  walls,  or  by  a  neoplasm  or  a  foreign  substance 
within  its  lumen,  may  become  at  a  moment  completely 
obstructed  by  any  of  the  causes  just  referred  to  when 
speaking  of  the  sudden  occlusion  of  strictures. 

The  patient  may  have  many  of  such  attacks,  and  these 
very  often  exhibit  an  increasing  degree  of  severity. 

With  regard  to  the  diagnosis  between  these  quasi-acute 
attacks  and  cases  of  acute  strangulation  of  the  bowel,  such 
as  may  be  due,  for  example,  to  bands,  the  most  important 
factor  is  the  patient's  past  history.  There  will  be  usually 
an  account  of  such  symptoms  as  have  been  described  as 
incident   to   chronic    obstructions,   and   there   will   probably 


438         CHRONIC    OBSTRUCTION  ENDING    ACUTELY. 

have  been  previous  attacks  of  like  character  but  of  less 
pronounced  severity. 

These  attacks  also  are  distinctly  less  abrupt  and  less 
violent  than  are  the  examples  of  acute  strangulation.  The 
pain  is  usually  by  no  means  so  severe,  nor  is  the  condition 
of  prostration  so  marked.  To  one  sign,  however,  in  the 
differential  diagnosis  too  much  importance  can  scarcely  be 
attached.  It  is  this.  In  the  acute  attack  supervening  in  a 
chronic  case,  the  coils  of  intestine  may  be  visible  through 
the  thinned  parietes,  a  symptom  which  will  be  absent  in 
cases  of  primary  acute  obstruction.  In  the  former  variety 
of  case  this  symptom  may  be  lost  sight  of  if  the  meteorism 
become  extreme,  or  if  peritonitis  develop,  and  it  may  be 
rendered  much  less  distinct  if  the  peristaltic  movements 
have  been  moderated  by  the  use  of  opium. 

There  are  unfortunately  a  few  cases,  as  has  been  already 
stated,  in  which  the  presence  of  a  partial  obstruction  of  the 
intestine  is  revealed  for  the  first  time  by  an  acute  attack. 
That  is  to  say,  a  stricture  exists  in  the  intestine  (most 
probably  in  the  small  intestine),  but  it  has  not  yet  so 
narrowed  the  lumen  of  the  tube  as  to  cause  definite 
obstructive  symptoms.  On  a  sudden,  however,  the  stenosed 
part  becomes  blocked  by  a  mass  of  undigested  food,  or 
the  bowel  becomes  occluded  by  kinking  at  the  seat  of 
stricture,  and  symptoms  are  thereby  produced  which  assume 
at  once  an  acute  character.  An  acute  attack  occurring  in 
these  circumstances  may  be  fatal,  and  there  are  cases  recorded 
where  a  stricture  of  the  small  intestine  has  revealed  itself  by 
one  attack  of  rapidly  developing  obstruction  which  has  ended 
in  death.  The  diagnosis  of  such  a  case  would,  in  the  present 
state  of  our  knowledge,  be  an  impossibility. 


439 


CHAPTER    X. 

THE  DIFFERENTIAL  DIAGNOSIS.  ERRORS  IN  DIAGNOSIS. 

The  diagnosis  of  intestinal  obstruction  is  not  alwaj^s  easy, 
especially  in  acute  cases  and  in  the  early  stages  of  the 
trouble.  Errors  are  common,  and  the  number  of  abdominal 
affections  which  have  at  one  time  or  another  been  mistaken 
for  intestinal  obstruction  are  very  numerous. 

In  the  present  chapter  the  more  common  of  these  sources 
of  error  are  dealt  with. 

1.  Acute  Abdominal  Troubles  other  than  Acute  Ob- 
struction.— Almost  an}^  acute  trouble  within  the  abdomen 
may,  during  the  first  few  hours  of  its  existence,  be  mistaken 
for  acute  intestinal  obstruction. 

As  examples  of  such  troubles,  may  be  given  the  passage 
of  a  gall  stone  or  of  a  renal  calculus,  the  twisting  of  the 
pedicle  of  an  ovarian  tumour,  the  perforation  of  the  intestine 
or  stomach,  the  rupture  of  a  cyst,  and  like  accidents. 

In  all  these  abruptly  appearing  conditions,  as  well  as  in 
acute  intestinal  obstruction,  there  is  one  common  and  pre- 
dominating factor — viz.  a  sudden  painful  impression  has  been 
made  upon  the  sensitive  and  widely  connected  abdominal 
nervous  system. 

From  a  clinical  point  of  view,  it  matters  little  whether  this 
painful  impression  is  produced  by  the  sudden  infecting  of  the 
peritoneum  by  escaping  noxious  germs  and  their  products  or 
whether  it  is  due  to  the  crushing  of  the  nerves  of  the  biliary 
passages  by  the  forcible  thrusting  of  a  gall  stone  along  a  tube 
whose  diameter  is  about  one-third  of  that  of  the  intruding 
substance. 

This  violent  disturbance  of  the  abdominal  nerves  produces 
certain  symptoms  which  are  practically  constant.  These  are 
intense  pain  in  the  abdomen,  localised  vaguely  about  the 
umbilicus  if  it  be  localised  at  all,  a  varying  degree  of  collapse, 


UO  DIFFERENTIAL   DIAGNOSIS. 

vomiting,  and  possibly  cessation  of  the  action  of  the  bowels. 
As  already  pointed  out,  to  these  common  symptoms  has  been 
applied  the  term  "peritonism,"  that  term  representing  the 
clinical  outcome  of  a  violent  disturbance  of  the  abdominal 
nerve  system  (page  290). 

The  symptoms  just  named  are  the  commencing  symptoms 
of  acute  intestinal  obstruction. 

These  early  symptoms  are  not  due  in  the  least  to  the  fact 
that  the  bowel  has  become  obstructed,  but  to  the  circumstance 
that  the  bowel  wall  has  been  violently  and  abrujDtly  injured 
(as  by  strangulation)  and  that  an  intense  impression  has  been 
made  upon  a  sensitive  system  of  nerves. 

It  is  no  matter  of  wonder  that  at  the  onset  of  the  trouble 
the  strangulation  of  a  loop  of  ileum  under  a  band  has  been 
mistaken  for  severe  hepatic  colic  in  a  patient  who  had 
repeatedly  passed  gall  stones,  or  that  the  twisting  of  the 
pedicle  of  an  unsuspected  ovarian  tumour  has  been  mistaken 
for  volvulus  of  the  sigmoid  flexure  in  a  patient  who  was  the 
subject  of  habitual  constipation. 

Twice  I  have  been  called  upon  to  operate  on  young  lads 
for  strangulated  inguinal  hernia  who  had  no  rupture  at  all. 
They  had  been  seized  with  violent  abdominal  pain,  had 
become  collapsed,  and  had  vomited.  The  pain  and  prostration 
had  continued,  and  the  vomiting  had  become  frequent  and 
persisting.  No  action  of  the  bowels  had  been  obtained  in 
spite  of  enemata.  Here,  then,  were  the  symptoms  of  acute 
intestinal  obstruction,  and  the  diagnosis  of  such  obstruction 
was  in  both  cases  encouraged  by  the  discovery  of  a  painful 
swelling  in  the  inguinal  canal  which  had  no  impulse  on 
coughing  and  was  irreducible.  The  symptoms  in  each 
instance  were  due  to  the  torsion  of  an  imperfectly  descended 
testicle,  and  the  bowel  was  in  no  way  interfered  with.  The 
testicles,  however,  are  well  supplied  with  nerves,  and  these 
nerves  are  in  very  close  relation  with  the  great  solar  flexus — 
in  as  close  a  relation,  indeed,  as  would  be  the  nerves  of  the 
colon.  The  symptoms  present  were  the  symptoms  which 
attend  an  abrupt  and  violent  impression  upon  any  section  of 
the  abdominal  nerve  system,  and  it  is  a  matter  of  little 
moment  (so  far  as  the  character  of  the  commencing  symptoms 
are  concerned)  whether  that  nerve  disturbance  depends  upon 
a  crushing  of  the  testicle  or  upon  the  strangling  of  a  loop  of 
bowel. 

Although  these  acute  troubles  bear  a  close  clinical  resem- 
blance to  one  another  at  the  very  commencement,  there 
soon  appear  in  most  cases  differentiating  signs  Avhich  make 
a  correct  diagnosis  possible. 


ACUTE    PERITONITIS.  441 

A  pelvic  examination  and  a  careful  inquiry  into  the 
past  history  of  the  case  reveal  the  ovarian  tumour  whose 
twisted  pedicle  has  given  rise  to  such  severe  disturbance ;  a 
distending  gall  bladder  and  the  onset  of  jaundice  mark  out 
the  case  of  hepatic  colic,  and  blood  ixa  the  urine  and  other 
symptoms  the  case  of  renal  stone.^ 

It  will  suffice  at  first  to  diagnose  the  acute  case  as  a 
case  of  "  peritonism."  A  few  hours  will  probably  make  clear 
the  cause  of  the  abrupt  impression  upon  the  abdominal 
nerves. 

2.  Acute  Peritonitis. — Among  the  most  frequent  errors 
in  diagnosis  in  connection  with  abdominal  disease  must  be 
placed  the  mistaking  of  acute  peritonitis  for  acute  intestinal 
obstruction. 

In  association  with  this  common  difficulty  in  diagnosis 
it  is  to  be  noted  that  when  errors  are  made  it  will  be  found 
that  peritonitis  has  been  mistaken  for  intestinal  obstruction 
rather  than  intestinal  obstruction  for  peritonitis. 

In  the  next  place  the  form  of  peritonitis  which  has  been 
most  often  the  basis  of  the  error  is  that  due  to  disease  ot 
the  vermiform  appendix,  and  next  in  frequency  to  this,  but 
very  much  less  common,  is  peritonitis  due  to  perforation  of 
the  stomach  or  bowel. 

Duplay,  in  an  excellent  monograph  upon  the  subject,  has 
collected  fourteen  recorded  examples  of  this  error  in  diag- 
nosis, t  and  more  modern  literature  teems  with  instances. 

In  each  instance  in  Duplay's  collection  the  case  was 
considered  to  be  one  of  acute  strangulation  of  the  bowel.  In 
several  of  the  examples  an  operation  was  performed  with 
the  intention  of  relieving  a  supposed  obstruction,  and  the 
error  was  only  discovered  when  the  abdomen  had  been 
opened.  The  great  majority  of  the  cases  were  examples  of 
peritonitis  following  upon  mischief  in  the  appendix.  In 
two  instances  the  cause  of  the  trouble  was  a  perforation  of 
the  gall  bladder.  In  an  example  of  peritonitis  due  to  this 
latter  cause,  reported  by  M.  Herbelin,  laparotomy  was  per- 
formed under  the  impression  that  the  case  was  one  of 
mechanical  obstruction.  J 

In  not  a  few  of  the  reported  cases  of  laparotomy  in  which 
a  "  volvulus  of  the  small  intestine  with  peritonitis "  was 
discovered,  there  is   little  doubt   but  that  the  surgeon  was 

*  Mayo  Eobson  reports  three  very  interesting  cases  in  which  hepatic  colic 
was  diagnosed  as  acute  intestinal  obstruction ;  Diseases  of  the  Gall  Bladder, 
1897,  p.  25. 

t  Archives  gen.  de  Med.,  vol.  xxviii.,  1876,  p.  513;  and  ibid.,  1879,  p.  709. 
{See  also  Henrot's  monograph. ) 

X  Bull,  de  la  Soc.  Anat.,  July,  1878. 


442  DIFFERENTIAL   niAGNOSIS, 

dealing  with  peritonitis  due  to  appendix  disease,  and  with 
an  arrangement  of  the  coils  of  small  intestine  which  was 
probably  not  abnormal. 

The  resemblance  between  the  cases  of  peritonitis  and 
those  of  acute  strangulation  is  often  close.  In  both  the 
symptoms  ma}'"  develop  suddenly  during  apparent  health 
or  after  certain  vague  abdominal  troubles,  in  both  there  is 
early  and  severe  pain,  in  both  there  are  constipation,  vomiting 
which  may  become  stercoraceous,  and  great  prostration. 

The  following  points  may  be  noticed  in  the  differential 
diagnosis. 

Mode  of  Onset. — In  both  it  is  usually  sudden,  and  more 
commonly  there  are  no  definite  distinguishing  symptoms. 
The  past  history  is  often  of  much  value  in  revealing  repeated 
attacks  of  perityphlitis  or  the  passing  of  gall  stones  or 
the  occurrence  of  pelvic  peritonitis,  hernia,  enteritis,  etc. 

Rigor. — A  rigor  may  usher  in  acute  peritonitis,  but  this 
symptom  is  exceedingly  rare  in  association  with  acute 
obstruction. 

The  teTYiperature  in  acute  peritonitis  is  usually  high  at 
first,  falling  again  as  prostration  advances.  In  certain  exam- 
ples, attended  by  profound  collapse,  the  temperature  may  be 
subnormal  from  the  first ;  but  such  cases  are  rare,  and  are 
not  likely  to  be  confounded  with  acute  strangulation.  In 
those  instances  of  peritonitis  where  this  confusion  is  apt 
to  occur  there  will  be  almost  always  a  distinct  elevation 
of  temperature  at  the  commencement  of  the  case,  and  this 
elevation  may  be  maintained  through  the  further  progress 
of  the  malady,  only  sinking  to  or  below  normal  at  the 
termination.  In  acute  diffuse  peritonitis  death  may  occur 
while  the  temperature  is  still  at  its  height.  The  earliest 
rise  of  temperature  may  reach  104°,  although  it  is  more 
usually  not  above  102°,  and  throughout  the  progress  of 
the  case  the  temperature  is  apt  to  show  marked  remis- 
sions. 

In  acute  obstruction,  on  the  other  hand,  the  temperature 
:low  at  first,  usually  subnormal,  and  remains  subnormal 
throughout  the  progress  of  the  case. 

Pain. — In  the  inflammatory  affection  the  pain,  which 
may  be  very  severe,  is  attended  by  extreme  tenderness  upon 
pressure.  This  tenderness,  which  may  be  at  first  local,  soon 
becomes  diffused.  The  pain  is  often  described  as  burning 
or  tearing. 

In  the  earlier  stages  of  the  obstructive  affection  there 
is  also  very  severe  pain,  but  there  is  no  marked  tender- 
ness, and,  indeed,  the    suffering   is   often   to   be  relieved  by 


TUBERCULOUS    PERITONITIS.  443 

pressure.  The  pain  is  usually  described  as  a  griping  pain 
which  Avould  be  relieved  if  flatus  could  be  passed. 

The  actual  pain  in  peritonitis  tends  to  diminish,  the  pain 
in  acute  obstruction  is  longer  maintained  in  its  intense  form. 

Voviiting. — In  both  maladies  vomiting  appears  early,  but 
in  acute  strangulation  it  is  a  much  more  prominent  symptom 
than  in  peritonitis. 

In  the  obstructive  condition  it  is  more  copious,  more 
persistent,  more  distressing,  and  more  apt  to  become  sterco- 
raceous.  In  peritonitis  the  vomited  matter  may  never  become 
stercoraceous,  or  only  towards  the  end  of  the  case. 

Constipation. — Constipation  is  absolute  in  the  obstruction 
cases.  In  peritonitis  it  may  be  absolute  also,  but  not  infre- 
quently slight  motions  are  passed  or  flatus  is  discharged  by 
the  anus. 

State  of  the  Abdomen. — The  abdominal  parietes  are  tense 
and  hard  from  the  first  in  diffused  peritonitis.  In  acute 
obstruction  they  are  flaccid  at  first,  and  often  remain  so  until 
peritoneal  inflammation  has  set  in. 

The  meteorism  may  be  localised  at  first  in  the  obstruction 
cases.     It  is  diffused  from  the  commencement  in  peritonitis. 

Intestinal  movements  may  occasionally  be  appreciated  in 
the  early  stages  of  obstruction,  but  no  such  movements  will 
be  apparent  in  peritonitis. 

Attitude  of  the  Patient. — In  acute  peritonitis  the  patient 
lies  quiet.  The  knees  are  drawn  up  and  the  hands  are  often 
held  above  the  head.  In  acute  obstruction  the  patient  is 
often  very  restless,  and  the  attitude  just  described  is  not 
observed. 

3.  Tuberculous  Peritonitis. — Cases  of  tuberculous  peri- 
tonitis have  been  mistaken  for  chronic  intestinal  obstruction. 
In  such  instances  some  swelling  can  be  usually  felt  in  the 
abdomen,  and  this  has  been  assumed  to  be  a  new  growth 
or  an  intussusception. 

The  progress  of  tuberculous  peritonitis  is  well  known 
to  be  uncertain,  and  to  be  marked  by  occasional  acute 
developments.  In  the  differential  diagnosis  of  these  con- 
ditions, however,  the  temperature  and  the  history  of  the 
case  are  of  the  greatest  assistance. 

In  chronic  tuberculous  peritonitis  coils  of  intestine  can 
often  be  seen  through  the  thinned  parietes,  and  constipation 
may  alternate  with  diarrhoea.  These  are  also  two  prominent 
features  in  chronic  obstruction. 

There  is,  however,  an  acute  form  of  tuberculous  peri- 
tonitis which  may  be,  and  has  been,  a  cause  of  error.  In 
this  form   the   disease   commences   acutely   with   a  pain  in 


444  DIFFERENTIAL    DIAGNOSIS. 

the. abdomen,  either  at  a  circumscribed  spot  or  over  a  larger 
area.  Associated  with  it  are  repeated  vomiting,  constipation, 
and  meteorism.  In  a  while  all  the  symptoms  may  disappear, 
and  then  repeated  attacks  occur  at  irregular  intervals.^ 
M.  Lionville  has  given  a  good  example  of  mistaken  diagnosis 
in  this  variety  of  tuberculous  peritonitis.  The  subject  was 
a  man,  aged  twenty- three,  who  was  taken  suddenly  ill  with 
symptoms  so  severe,  and  so  like  those  of  intestinal  obstruc- 
tion, that  an  operation  for  his  relief  was  proposed.  In  four 
clays  the  bowels  were  opened  spontaneously;  the  vomiting, 
which  had  been  almost  fseculent,  disappeared  and  the  patient 
returned  to  what  seemed  to  be  a  condition  of  health.  In 
fifteen  days,  however,  the  symptoms  of  intestinal  obstruction 
appeared  again,  and  again  was  an  operation  seriously  con- 
sidered. The  symptoms  again  passed  off.  The  patient 
died  in  three  months,  and  the  autopsy  revealed  nothing 
but  the  ordinary  evidences  of  tuberculous  peritonitis,  t 

In  the  differential  diagnosis  of  these  affections  it  is 
especially  to  be  noticed  that  the  tuberculous  disorder  is 
attended  by  fever,  and  by  early  and  usually  distinct  tender- 
ness of  the  abdomen.  These  symptoms  are  absent  in  the 
obstruction  cases.  After  the  attack  there  is  usually  a  sense 
of  undue  resistance  over  the  spot  that  has  been  especially 
the  seat  of  pain  and  tenderness. 

During  the  progress  of  any  case  of  tuberculous  peritonitis, 
genuine  intestinal  obstruction  may  occur  from  matting 
together  of  the  coils  of  intestine,  or  from  bending  or  kinking 
of  such  hoops  as  are  adherent. 

4.  Other  Diseases  which  have  been  Mistaken  for  Obstruc- 
tion of  the  Bowels. — Under  this  heading  I  propose  merely  to 
enumerate  a  few  of  the  maladies  which  have  been  mistaken 
for  cases  of  intestinal  obstruction ;  but  not  to  discuss  the 
differential  diagnosis  in  each  instance,  since  many  of  these 
examples  of  mistaken  diagnosis  have  been  already  referred  to, 
and  the  symptoms  of  each  variety  of  occhision  have  been,  on 
the  other  hand,  fully  discussed.  Moreover,  these  examples  of 
error  are  exceedingly  uncommon. 

Cholera. — This  disease  has  been  imitated  by  the  most 
acute  forms  of  intestinal  obstruction.  In  these  cases  the 
patient  has  fallen  rapidly  into  a  condition  of  cholera-like 
collapse  ;  the  extremities  have  become  cool,  the  surface 
cyanosed,  the  pulse  thready  and  almost  imperceptible,  the 
voice  has  sunk  to  a  whisper,  and  the  countenance  has  presented 

*  Bauer ;  Diseases  of  the  Peritoneum.     Ziemssen's  Cyclopaedia  of  Medicine, 
vol.  viii.,  p.  328. 

t  Bull,  de  la  Soc.  Anat.  de  Paris,  1875,  p.  726. 


CHOLERA.  445 

all  the  features  observed  in  cholera.  At  the  same  time  there 
have  been  a  violent  vomiting,  cramps  in  all  the  limbs,  suppres- 
sion of  urine,  and  extreme  prostration.  The  cases  that  have 
most  closel}^  resembled  cholera  have  been  cases  of  very  acute 
strangulation  of  a  considerable  portion  of  the  small  intestine, 
and  especially  of  the  upper  parts  of  that  bowel.  The  strangu- 
lation may  have  been  preceded  by  profuse  diarrhoea,  or  the  gut 
below  the  obstruction  may  have  been  emptied  by  diarrhoea  after 
the  strangulation  had  occurred."^  In  many  instances  in  which 
error  in  diagnosis  had  occurred,  the  cases  had  been  met  with 
during  an  epidemic  of  cholera. 

Another  form  of  obstruction  which  may  resemble  cholera 
is  ultra-acute  intussusception  associated  probably  with  much 
purging,  t 

Dr.  Barlow  mentions  an  instance  where  the  patient  was 
thrown  into  a  choleraic  condition  from  obstruction  due  to 
masses  of  undigested  food.  J  A  like  case  of  a  more  severe 
character  is  quoted  in  Dr.  Servier's  treatise.  In  this  instance 
the  patient,  a  soldier,  lived  only  sixteen  hours  after  the  com- 
mencement of  the  attack.  § 

An  excellent  discussion  of  the  chief  features  in  the  diag- 
nosis of  these  cases  has  been  afforded  by  M.  Felix  Refrege.|| 
He  deals  with  fourteen  cases  of  error  in  diasrnosis,  and  refers 
to  other  but  less  defined  examples. 

In  only  four  of  the  fourteen  cases  were  cramps  in  the 
limbs  noticed,  and  in  all,  save  in  two  examples,  there  was 
absolute  constipation. 

There  can  be  little  real  difficulty  in  the  diagnosis  if  too 
hurried  an  opinion  be  not  arrived  at.  The  obstruction  attacks 
are  associated  with  intense  pain  at  the  commencement 
attended  by  constipation.  In  cholera  there  is  an  absence  of 
pain  and  profuse  diarrhoea.  The  abdomen  becomes  soon 
retracted  in  cholera,  but  meteoristic  in  acute  strangulation. 
In  cholera  vomiting  does  not  set  in  quite  so  early  as  in  cases 
of  acute  obstruction.  In  man}''  cases  it  is  entirely  absent,  and 
when  present  is  non-fseculent,  and  has  the  peculiar  whey-like 
appearance  so  often  described. 

*  Fournier  and  OUivier ;  Gaz.  Med.  de  Paris,  1868.  The  motions  were  not 
arrested  until  two  days  before  death.  See  also  Touchard ;  Note  sur  un  cas 
d'occlusion  intestinale  avec  diarrhee  ;  Progres  medical,  No.  5,  p.  83,  1892. 

f  Dr.  Todd:  Med.  Times  and  Gazette,  vol.  ii.,  1865,  p.  195.  M.  Eernett ;  Bull, 
de  la  See.  Anat.,  1863,  p.  296. 

+  3Ied.  Times,  vol.  i.,  1866,  p.  443. 

§  LTTnion  Med.,  1867,^p.  100, 

II  Le  Diagnostic  de  rEtranglement  intestinal  a  Symptomes  choleriformes. 
These  de  Paiis,  1867.  See  also  art.  by  M.  Berger,  Bull.  et.  Mem.  de  la  Soc.  de 
Chir.  de  Paris,  vol.  ii.,  1876,  p.  698;  and  Vassor,  These  de  Paris,  1862;  and 
Savopoulo,  These  de  Paris,  1854. 


446  DIFFERENTIAL    DIAGNOSIS. 

Error  is  iLiost  likely  to  occur  when  an  example  of  ultra- 
acute  occlusion  is  met  with  during  an  epidemic  of  cholera. 

Lead  colic. — A  case  is  reported  by  Dr.  Fagge*  of  a  man, 
aged  twenty-nine,  who  had  a  blue  line  on  the  gums,  but 
whose  intestinal  symptoms  were  due  not  to  lead-poisoning,  as 
was  at  first  supposed,  but  to  partial  obstruction  from  shrinking 
of  the  mesentery. 

I  have  seen  a  case  of  lead  colic  which  had  been  diagnosed 
at  first  as  hepatic  colic,  and  later  in  the  day  as  acute  intestinal 
obstruction. 

Poisoning  by  arsenic. — In  several  instances  cases  of  acute 
strangulation  have  excited  suspicion  of  poisoning  by  arsenic, 
and  the  doubt  has  only  been  cleared  up  at  the  autopsy. 
Leichtenstern  alludes  to  several  examples. 

Meningitis. — Dr.  Fagge  alludes  to  a  case  of  acute  obstruc- 
tion of  the  jejunum  where  meningitis  was  suspected  on 
account  of  the  dehrium,  the  vomiting,  and  the  retracted 
abdomen. 

Cirrhosis  of  the  liver. — Dr.  Lusseau  reports  a  case  where 
cirrhosis  of  the  liver  was  taken  for  an  example  of  obstruction 
of  the  commencement  of  the  colon  by  a  neoplasm.  The 
autopsy,  however,  revealed,  in  addition  to  the  cirrhosis,  some 
old  adhesions  about  the  cascum  and  sigmoid  flexure,  as  well 
as  a  compression  of  the  third  part  of  the  duodenum,  by  an 
old  cicatricial  band.f  There  was  possibly,  therefore,  real 
obstruction. 

Sarcoma  of  the  omentum  has  simulated  true  obstruction,^ 
and  the  tumour  formed  has  been  mistaken  for  fsecal  masses. 

A  cyst  of  the  mesentery  has  been  mistaken  for  an  intussus- 
ception tumour,§  and  an  intussusception  tumour  for  a  new 
growth,  a  mass  of  fffical  matter,  or  other  swellings. 

Tumours  formed  by  fsecal  masses  have  been  mistaken  for 
a  number  of  affections  {see  page  426),  and  notice  has  already 
been  taken  of  the  numerous  diseases  which  have  been  con- 
fused with  chronic  intussusception.     {8ee  page  418.) 

The  confusion  between  acute  or  subacute  intussusception 
and  dysentery  or  enteritis  has  been  of  frequent  occurrence. 

Hysteria. — It  is  scarcely  necessary  to  mention  that  in  the 
more  perverse  form  of  neurotic  subject  the  phenomena  of 
intestinal  obstruction  of  a  chronic  type  may  be  imitated.  The 
imitation  is,  hoAvever,  never  very  close  and  would  deceive  no 
one  but  a  fond  mother. 

*  Guy's  Hospital  Eeports,  vol.  xiv.,  p.  272. 

t  Pr ogres  Medical,  1879,  p.  545. 

+  De  rOcclusion  Intestinale.     These  de  Paris,  1897,  No.  363. 

I  Bull,  de  I'Acad.  de  Med.,  p.  831.     Paris,  1880. 


TB0MB08IS    OF    THE    MESENTEBIQ    VESSELS.      447 

Thrombosis  of  the  mesenteric  veins. — This  condition  may 
imitate  intestinal  obstruction.  A  good  illustrative  case  has 
been  furnished  by  Dr.  Rose  Bradford."^ 

The  patient  was  a  carman,  aged  twenty,  who  was  admitted 
into  hospital  on  August  26th,  having  suffered  from  pains  in 
the  abdomen,  some  sickness,  sh'ght  diarrhoea,  and  headache  for 
six  days. 

The  pain  in  the  abdomen  was  referred  to  the  umbilicus. 
The  abdomen  was  neither  tender  nor  distended,  and  presented 
no  abnormality  on  examination.  The  respirations  were  rapid, 
shallow,  and  jerky.  The  temperature  fluctuated  between  100° 
and  101°.  The  sickness  continued,  and  the  diarrhoea  was 
replaced  by  constipation.  On  September  1st  the  vomiting 
became  severe,  and  the  pain  in  the  abdomen  more  intense. 
The  temperature  sank  to  99"6°.  The  vomiting  became  ster- 
coraceous;  an  indefinite  mass  like  a  coil  of  bowel  was  felt  in 
the  left  iliac  fossa ;  the  bowels  ceased  to  act.  On  September 
3rd  the  temperature  was  96° ;  the  vomiting  was  still  severe  ; 
there  was  a  rigor  followed  by  collapse.  Laparotomy  was  per- 
formed, no  obstruction  was  found,  and  the  patient  died  very 
shortly  after  the  wound  was  closed.  The  autopsy  revealed 
phlebitis  and  thrombosis  of  the  superior  mesenteric  vein. 
The  jejunum  was  congested  for  several  feet  from  its  com- 
mencement, and  one  coil,  eighteen  inches  in  length,  was 
greatly  thickened  and  swollen,  and  of  a  dark  purple  colour. 
The  cause  of  the  thrombosis  was  not  clearly  demonstrated. 
There  seems  to  have  been  a  little  peritonitis  present. 

See  also  papers  by  Barthf  and  Koster.J 

Thrombosis  of  the  mesenteric  arteries. — This  condition 
may  lead  to  quite  acute  symptoms,  and  may  imitate  acute 
mtestinal  obstruction.  In  thrombosis  of  the  mesenteric  veins 
more  chronic  types  of  obstruction  are  imitated.  As  examples 
the  following  cases  may  be  alluded  to.  Dr.  T.  E.  Gordon§ 
reports  the  case  of  a  woman,  aged  forty-nine,  who  was  suddenly 
seized  with  severe  abdommal  symptoms,  closely  resembling 
those  of  acute  strangulation  of  the  bowel.  Laparotomy  was 
performed  and  a  thrombosis  of  the  superior  mesenteric  artery 
was  discovered  with  hsemorrhagic  infarction  of  a  portion  of 
the  small  intestine.  Two  feet  of  the  bowel  were  resected 
with  success. 

The  following  case  is  reported  by  Dr.  Monro :  H 

*  Clin.  Soc.  Trans.,  1898,  p.  203. 

t  Semaine  Medicale,  1897,  page  395. 

J  Deut.  med.  Wochen.,  1898,  May  26. 

§  £rU.  Med.  Journ.,  vol.  i.,  1898,  page  1447. 

11  Lancet,  vol.  i.,  1894,  page  147. 


448  DIFFERENTIAL    DIAGNOSIS. 

A  man,  ag-ed  fifty- one,  while  lifting  a  weight  felt  a 
peculiar  sensation  in  the  lower  part  of  the  belly,  followed  by 
pain  and  exhaustion.  A  few  hours  afterwards  he  passed  from 
a  pint  to  a  pint  and  a  half  of  blood  by  the  bowel. 

The  symptoms  then  took  the  form  of  colicky  pains  with 
marked  constipation  and  great  weakness.  There  was  some 
vomiting,  the  tongue  was  foul  and '  the  temperature  sub- 
normal.    The  bowels  at  last  failed  to  respond  to  purgatives. 

The  abdomen  was  distended  and  a  hard  mass,  the  size 
of  an  orange,  was  found  in  the  left  iliac  fossa.  Laparotomy 
was  performed  after  the  symptoms  had  existed  for  three 
weeks. 

The  mass  in  the  iliac  fossa  was  due  to  an  infarction  in  the 
sigmoid  mesocolon.  The  colon  was  enormously  distended 
and  dark  in  colour.  The  principal  lesion  was  evidently  a 
thrombosis  of  the  inferior  mesenteric  artery.  The  patient 
died  twenty  hours  after  the  operation. 


Ud 


PART    III. 
TREATMENT. 


CHAPTER    I. 

THE  GENERAL    TREATMENT  OF  ACUTE  INTESTINAL 
OBSTRUCTION. 

The  bases  of  the  treatment  of  this  condition  may  be  con- 
sidered under  the  following  headings :  I.  Rest.  2.  The 
administration  of  morphia.  3.  The  evacuation  of  the  lower 
bowel.  4.  The  question  of  feeding.  5.  The  use  of  measures 
other  than  operation ;    and  6.  The  treatment  by  operation. 

The  tirst  five  of  these  measures  will  now  be  dealt  with. 
The  operative  treatment  of  acute  intestinal  obstruction  will 
be  considered  in  the  next  chapter. 

1.  Rest. — It  is  probable  that  the  patient  when  first  seen 
will  be  already  in  bed.  It  is  needless  to  say  that  he  must 
be  kept  at  rest  in  the  recumbent  position.  It  is  not  neces- 
sary to  insist  that  he  should  keep  motionless,  as  after  an 
abdominal  operation.  The  subjects  of  acute  intestinal 
obstruction  are  often  very  restless,  and  there  is  no  purpose 
in  restraining  their  movements.  Some,  indeed,  are  more 
comfortable  when  lying  upon  one  side,  with  the  knees 
drawn  up. 

The  majority  lie  flat  upon  the  back,  and  this  is  the 
posture  to  be  encouraged.  A  bed-cradle  adds  to  the 
patient's. comfort.  It  removes  the  weight  of  the  bed-clothes 
from  the  abdomen  and  knees,  and  rids  the  much-oppressed 
sufferer  of  a  feeling  of  restraint. 

If  an  abdominal  operation  be  carried  out,  the  bed- cradle 
becomes  a  necessit}^ 

The  bed  should  be  narrow  and  the  mattress  firm.  It 
is  hopeless  to  attempt  to  deal  with  patients  wallowing  in 
the  trough  of  an  enormous  feather  bed.  When  so  placed 
they  cannot  be  properly  examined,  or  properly  nursed  or 
properly  handled,  and  such  a  bed — which  is  often  a  feature 

D  D 


ioO  TREATMENT    OF   ACUTE    OBSTRUCTION. 

of  the  modern  "  best  bedroom  " — is  an  impossibility  after  an 
abdominal  section. 

2.  The  Administration  of  Morphia. — Morphia  is  an 
absolute  necessity  in  acute  intestinal  obstruction,  and  should 
be  administered  with  as  little  delay  as  possible. 

It  eases  the  agonising  pain  and  gives  the  patient  a 
respite  from  what  is  without  doubt  one  of  the  most  terrible 
forms  of  human  suffering. 

Pain,  moreover,  may  be  taken  as  some  measure  of  the 
degree  of  shock,  and  with  the  subsidence  of  the  pain  the 
more  striking  manifestations  of  collapse  become  less  marked  or 
disappear.  The  drug  not  only  affects  the  pain,  but  it  influences 
the  pulse  and  temperature.  One  of  the  cases  reported  by 
Leichtenstern  in  his  monograph  may  be  taken  in  illustration 
of  this.  "  A  few  days  ago  I  saw,"  he  writes,  "  an  unusually 
severe  case  of  obstruction  by  gall  stones  ;  the  patient  was 
covered  with  cold  sweat,  had  cool  extremities,  muffled  voice, 
choleraic  countenance,  vomited  freely,  and  presented  a  board- 
like tension  of  the  abdomen.  The  temperature  in  the  rectum 
was  95'5°  ;  a  thermometer  placed  at  the  same  time  in  the 
axilla,  and  compared  with  the  one  in  the  rectum,  marked 
only  92° ;  the  pulse  was  small,  its  frequency  forty-eight  in 
the  minute.  After  an  injection  of  morphia,  the  tension  of  the 
abdomen  diminished,  the  skin  fllled  with  blood,  the  pulse  rose 
gradually  to  seventy- six,  and  the  temperature  in  the  rectum, 
after  the  patient  had  passed  an  hour  of  comparative  comfort, 
was  99"6°."*  Besides  all  this,  in  such  cases  the  expression  of 
the  face  returns  more  to  its  normal  condition.  The  pinched 
appearance  is  gradually  lost,  the  eyes  appear  less  sunken,  and 
the  lips  less  blue.  The  dry  tongue  becomes  moist,  the  sweat 
ceases  to  pour  from  the  face,  the  intellectual  faculties  revive, 
and  the  patient  passes  from  a  state  of  intense  terror  and 
anxiety  to  a  condition  of  comparative  repose.  I  have  no 
doubt  that  in  many  severe  cases  death  early  in  the  case 
from  shock  has  been  averted  by  the  timely  injection  oi 
morphia. 

Upon  the  quantity  of  the  urinary  secretion  the  effects  of 
opium  are  often  very  marked.  Before  the  administration 
of  the  drug,  and  during  the  presence  of  the  collapse  symp- 
toms, there  may  be  oliguria,  or  apparent  suppression  of  urine, 
but  after  the  administration  of  the  narcotic  a  copious  secre- 
tion of  urine  is  one  of  the  commonest  evidences  of  its 
beneficial  effects. 

So  remarkable  may  be  the  effect  of  one  injection  of 
morphia  in  acute  intestinal  obstruction  that  I  have  known 

.     •  *  Ziemssen's  Cyclopsedia  of  Medicine,  vol.  vii.,  p.  499. 


MOBPHTA.  451 

a  case — which  ultimately  ended  in  death  from  strangulation 
— in  which  the  symptoms  were  supposed  to  have  been  due 
to  colic  and  to  have  passed  away  under  the  influence  of 
the  drug.  Under  this  impression  the  patient  was  allowed  to 
get  up. 

Morphia,  moreover,  restores  for  the  time  being  a  state  of 
peace  within  the  disturbed  abdomen  The  disordered  peri- 
staltic niovements  which  are  associated  with  the  onset  of  the 
attack  are  brought  to  rest,  and  the  symptoms  due  to  reflex 
nerve  disturbance  are  reduced  to  temporary  insigniflcance. 

Thus  it  happens  that  under  the  influence  of  the  drug  the 
vomiting  may  cease  or  become  quite  trifling,  and  the  sense 
of  disturbance  within  the  belly  cavity  may  almost  vanish. 

The  part  which  disordered  and  excessive  peristaltic  move- 
ments may  play  in  the  production  and  aggravation  of  certain 
forms  of  acute  obstruction  makes  it  most  desirable  that  these 
movements  should  be  checked  as  soon  as  possible.  A  coil 
may  be  lightly  held  beneath  a  loose  band,  but  luider  the 
influence  of  violent  peristalsis  in  the  adjacent  loops  a  large 
amount  of  intestine  may  be  drawn  beneath  the  now  tense 
cord  and  strangulation  of  a  severe  type  be  produced. 

.  Dr.  Hoar  has  recorded  the  case  of  a  middle-aged  lady 
upon  whom  I  operated  for  repeated  attacks  of  intestinal  ob- 
struction of  a  subacute  type.  The  laparotomy  showed  that 
there  was  a  remarkable  gap  in  the  sustentaculum  lienis 
through  which  there  could  be  no  doubt,  from  the  situation  of 
the  pain,  etc.,  that  bowel  had  been  snared. 

In  this  instance  the  attacks  which  had  occurred  previously 
to  the  operation  had  yielded  to  atropine  or  morphia,  and  it 
must  be  inferred  that  as  soon  as  the  disturbed  intestine  was 
brought  to  a  state  of  rest  the  engaged  bowel  could  withdraw 
itself  from  its  hazardous  position."^ 

A  case  of  a  different  type  is  reported  by  M.  Le  Fort.  A 
young  man  received  a  kick  upon  the  belly  from  a  horse.  Some 
days  afterwards  he  developed  symptoms  of  internal  strangula- 
tion. Opium  was  at  once  administered  every  one  or  two 
hours.  The  symptoms  passed  away.  The  patient's  appetite 
returned ;  his  bowels  were  freely  opened  ;  he  got  up.  Before 
long,  however,  gurgling  would  begin  in  the  abdomen,  associated 
with  energetic  movements  of  the  intestine  and  subsequently 
with  much  meteorisin.  These  symptoms  were  soon  followed 
by  vomiting,  pain,  and  the  other  evidences  of  intestinal  ob- 
struction. Under  the  influence  of  opium  all  these  symptoms 
subsided  and  the  patient  was  soon  well  again.  Within  two 
months  the  patient  had  three  attacks  of  internal  strangulation 

*  Hrlt.  Med.  Journal  April  20,  1895. 


4-52  TREATMENT    OF   ACUTE    OBSTRUCTION. 

which  yielded  to  opium.  The  fourth  attack  was  associated: 
with  peritonitis,  of  which  he  died.  The  autopsy  revealed  two 
hernise  of  the  small  intestine  through  two  rents  in  the  great; 
omentum,  which  rents  were  no  doubt  produced  at  the  time 
of  the  accident.  Here  it  would  seem  that  while  the  intestines 
were  still,  and  their  contents  quietly  propelled,  the  narrowing 
of  the  gut  was  not  sufficient  to  cause  obstruction.  But  when 
the  peristaltic  movements  became  active  and  the  contents 
were  hurried  along,  the  involved  coils  became  obstructed  and 
symptoms  were  immediately  produced."^ 

It  is  easy  to  imagine  also  that  a  volvulus  in  process  of 
formation  may  be  arrested  by  the  prompt  administration 
of  morphia,  or  even  that  the  untwisting  of  a  volvulus  when 
once  formed  may  be  rendered  possible  by  the  arrest  of  all 
movement  in  the  disturbed  bowel. 

In  the  history  of  certain  cases  of  volvulus  of  the  sigmoid 
flexure  there  are  accounts  of  "  previous  attacks,"  or  at  least 
of  attacks  of  severe  intestinal  pain,  which  vanished  under 
morphia,  and  it  is  at  least  conceivable  that  some  of  these 
attacks  might  have  been  due  to  an  abortive  tw^isting  of  the 
bowel. 

The  value  of  opium  in  the  treatment  of  intussusception 
can  scarcely  be  over-estimated.  In  this  condition  the  very 
origin  of  the  invagination,  as  well  as  its  progress,  depends  upon 
disordered  peristaltic  movements.  Some  of  the  most  dis- 
tressing symptoms  of  the  affection  are  due  to  these  move- 
ments. Opium  arrests  them.  When  the  patient  is  fully 
under  the  influence  of  the  drug  the  intestines  would  appear 
to  be  still,  an  increase  of  the  intussusception  is  scarcely 
possible,  and  the  troubled  parts  have  all  the  advantages  of 
physiological  rest.  When  once  the  irregular  peristaltic  move- 
ments are  brought  into  abeyance  a  most  favourable  oppor- 
tunity is  offered  to  the  part  to  return  to  its  normal  condition. 
I  have  not  the  least  doubt  that  many  cases  of  acute  intussus- 
ception have  yielded  to  the  early  administration  of  opium,, 
and  it  is  not  improbable  that  many  of  the  examples  of  the 
"  cure  "  of  acute  strangulation  by  opium  belong  really  to  this 
pathological  division. 

Some  of  the  reported  cases  of  obstruction  that  have 
spontaneously  yielded  under  the  effects  of  opium  are  not 
easily  explained.  As  an  example  of  this  may  be  cited  the 
following :  Mr.  Brewer  records  the  case  of  a  man,  aged  forty- 
nine,  who  presented  the  s^'mptoms  of  acute  obstruction.  The 
condition  was  ascribed  to  a  too  hearty  meal  of  steak-pudding. 
Aperients  were  at  first  administered,  but  only  with  the  efl'ect 
*  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1879,  p.  635. 


MORPHIA.  45.1 

of  increasing  the  trouble.  The  subsequent  treatment  con- 
sisted of  opium,  the  use  of  enemata,  and  poultices.  The 
enemata  had  no  eft'ect,  and,  indeed,  provoked  vomiting. 
The  action  of  the  poultices  may  be  considered  as  nil, 
and  the  treatment  therefore  is  reduced  to  rest  and  opium. 
The  man  had  all  the  symptoms  of  internal  strangulation, 
the  vomiting  was  severe  and  became  stercoraceous.  There 
was  absolute  constipation  for  eleven  days.  At  the  end  of 
that  time  a  motion  was  passed  spontaneously  and  the 
patient  made  a  rapid  recovery."^ 

While  morphia  is  of  gTeat  value  in  relieving  the  more 
urgent  and  distressing  of  the  symptoms,  it  must  also  be 
observed  that  its  use  may  seriously  obscure  the  diagnosis 
in  any  case  of  acute  strangulation.  It  may  so  modify  the 
s3Tiiptonis  and  so  atfect  the  general  aspect  of  the  case  that 
the  more  characteristic  manifestations  of  the  malady  are 
put  entirely  in  abeyance.  If  the  pain  be  modified  or  re- 
lieved, if  the  symptoms  of  collapse  be  absent  or  but  dimly 
marked,  if  the  vomiting  be  slight  and  of  httle  moment,  and 
if  the  patient  appear  to  be  in  a  state  of  comparative  ease, 
some  of  the  chief  factors  needed  for  a  proper  diagnosis  will 
be  wanting.  This  is  Avell  illustrated  in  cases  of  strangulated 
hernia,  especially  in  old  persons.  The  symptoms  may  in 
these  cases  be  at  first  typical  enough,  but  when  opium  is 
administered  they  become  not  only  obscured  but  misleading. 
The  evidences  of  pain  and  prostration  become  indistinct, 
the  dry  tongue  becomes  moist,  the  pulse  improves,  the 
excretion  of  urine  is  normal,  the  abdomen  is  the  seat  of  no 
severe  pain,  the  hernia  is  not  especially  tender,  the  vomiting 
has  ceased  or  has  become  very  much  diminished.  In  short, 
the  patient's  symptoms  have  apparently  improved,  while  the 
state  of  the  herniated  bowel  has  become  worse  and  worse. 
I  have  twice  had  under  my  care,  in  the  London  Hospital, 
elderly  patients  with  strangulated  hernise,  who  had  been 
freely  drugged  with  opium  before  admission,  and  who  had 
lost  the  more  conspicuous  evidences  of  strangulation.  In 
both  there  was  prostration,  in  both  there  was  an  absence 
of  pain,  in  both  the  vomiting  had  become  much  less  marked 
than  it  had  been,  and  in  both  the  hernial  tumour  was 
becoming  soft  through  gangrene. 

In  like  manner,  in  cases  of  internal  strangulation,  the 
symptoms  ma.y  be  so  im.proved  and  so  modified  by  the  free 
administration  of  opium  that  the  clinical  outline  ot  the  case 
may  become  utterly  blurred,  and  serious  errors  in  the  diagnosis 
result  in  consequence. 

*  Lancet,  vol.  ii.,  1874,  p.  726 


454  TREATMENT    OF   ACUTE    OBSTRUCTION. 

Examples  of  this  obliteration  ot"  the  phenomena  of  disease 
by  morphia  must  have  come  under  the  notice  of  every 
hospital  surgeon.  I  have  been  called  to  see  patients  who  were 
actually  dying,  and  in  whom  an  autopsy  revealed  a  coil  of 
strangulated  and  utterly  gangrenous  bowel.  These  patients 
had  been  dosed  from  the  first  with  morphia,  and  had  died 
without  giving  a  sign.  The  suggestion  that  they  were  dying 
of  strangulation  of  the  bowel  has  been  met  with  the  question, 
"  Where  are  the  symptoms  ? "  It  has  been  pointed  out  that 
there  Avas  no  pain  after  the  initial  attack,  and  little,  if  any 
vomiting  after  the  patient  came  under  treatment.  The  belly 
was  not  grossly  distended,  an  enema  had  led  to  one  or  more 
evacuations  of  the  bowels,  and  it  was  stated  that  until  the 
phenomena  of  death  appeared  the  patient  was  cheerful,  the 
tongue  moist,  and  the  pulse  good. 

Yet  morphia  can  do  all  this  and  more. 

It  can  disguise  the  very  image  of  death,  and  make  almost 
a  mock  of  dying.  And  it  is  evident  from  such  cases  as  are 
now  under  consideration  that  the  delusions  and  the  visions 
begot  by  morphia  are  not  limited  to  the  takers  of  the  drug. 

It  must  also  be  remembered  that  the  initial  symptoms  of 
acute  intestinal  obstruction  are  not  always  very  well  marked. 
These  initial  symptoms  are  those  which  have  been  described 
under  the  title  of  "  peritonism "  as  symptoms  which  may 
mark  the  onset  of  any  acute  and  painful  accident  within  the 
abdomen.  Here  is  a  patient  in  sound  health,  who  has  been  sud- 
denly stricken  with  an  agony  in  the  abdomen,  with  vomiting 
and  with  collapse.  In  most  cases  time  alone  will  show  whether 
the  symptoms  are  due  to  an  internal  strangulation,  or  to  the 
passage  of  a  gall  stone,  or  to  the  twisting  of  the  pedicle  of  an 
ovarian  tumour,  or  to  some  other  acute  mischief.  If  there  be 
a  history  of  an  ovarian  tumour,  or  of  the  passage  of  previous 
gall  stones,  or  if  an  irreducible  hernial  tumour  exist,  the 
diagnosis,  with  the  aid  of  some  few  additional  facts,  may  be 
easy  enough.  But  in  many  instances  there  are  no  guiding 
lights  and  the  surgeon  must  wait  for  differentiating  signs 
before  he  can  be  sure  of  his  diagnosis.  In  the  meantime  the 
patient  is  in  the  direst  pain  and  morphia  must  be  administered. 
If,  however,  there  be  not  caution  in  this  administration  those 
differentiating  signs  may  not  be  clearly  manifest,  or  may,  at 
least,  be  rendered  less  emphatic. 

In  the  employment  of  morphia  in  acute  intestinal  obstruc- 
tion the  rules  should  be  as  follow  : 

1.  Morphia  must  be  given  to  relieve  the  pain. 

2.  The  least  amount  which  will  effect  this  end  should  be 
the  amount  given. 


MORPHIA.  455 

In  the  case  of  an  adult  with  quite  acute  symptoms,  one- 
fourth  of  a  grain  of  morphia  should  be  administered  hypo- 
dermically  at  once,  and  if  the  pain  be  not  subdued  the 
subsequent  doses  should  be  not  more  than  one-sixth  of  a 
grain  given  at  as  long  intervals  as  are  possible. 

In  the  case  of  an  adult  with  symptoms  not  of  the 
extremest  degree,  the  initial  dose  may  be  one-sixth  of  a 
grain,  to  be  repeated .  in  one  or  two  hours  if  absolutely 
necessary.  It  is  to  be  remembered  that  patients  vary 
greatly  as  to  their  susceptibility  to  this  drug. 

One-sixth  of  a  grain  may  restore  a  strong  man  from  a  state 
of  agony  and  collapse  to  a  condition  of  comparative  comfort 
and  apparent  well-being. 

A  small  dose  can  always  be  added  to,  but  a  large  dose  can- 
not be  taken  from. 

The  surgeon,  impressed  with  the  fearful  sufferings  of  the 
patient  and  the  alarmingly  sudden  onset  of  the  trouble,  is  apt 
to  give  at  once  a  heroic  dose,  suited,  as  he  thinks,  to  heroic 
conditions.  Under  the  influence  of  this  impression  I  have 
known  one-half  of  a  grain  of  morphia  to  be  given  at  once, 
followed  in  twenty  minutes  by  another  half  grain,  because  the 
patient  was  still  groaning.  These  two  doses  have  reduced  the 
patient  to  the  clinically  negative  condition  of  a  deeply 
stupefied  individual. 

Some  surgeons  advise  that  in  any  case  the  dose  be  small — 
one-tenth  to  one-sixth  of  a  grain — on  the  grounds  that  a  small 
dose  will  give  as  certain  relief  as  a  large  one.  This,  however, 
has  not  been  my  experience,  and  I  think  the  advocacy  of  the 
small  dose  is  possibly  based  upon  an  exceptional  experience  of 
susceptible  patients  in  Avhose  cases  the  dose  of  one-tenth  or 
one-eighth  of  a  grain  may  be  amply  sufficient  to  secure  ease. 

I  have  certainly  seen  more  harm  from  giving  too  much 
morphia  than  from  giving  too  little. 

My  impression  is  that  quite  a  small  dose  will  usually  suffice 
to  arrest  irregular  peristaltic  action.  In  any  case  it  is  safe  to 
say  that  the  less  morphia  given  the  better.  Morphia  has  the 
ultimate  effect  of  rendering  the  patient  unduly  sensitive  to 
painful  impressions.  This  undoubted  effect  is  to  be  noticed  as 
soon  as  the  immediate  narcotic  influence  of  the  drug  is  passing 
away.  The  confirmed  morphia  taker  under  the  influence  of 
the  contrast  between  the  morphia  state  and  the  non-morphia 
state  is  very  apt  to  exaggerate  his  miseries  when  the  effect 
of  the  drug  has  passed  off  in  order  to  enlist  the  sympathies  ot 
the  surgeon  with  the  much- worshipped  syringe ;  but  in  the 
case  of  the  sufferer  from  intestinal  obstruction,  who  has 
experienced  only  the  blessings  of  a  few  doses,  there  can  be  no 


456  TREATMENT    OF   ACUTE    OBSTRUCTION. 

doubt  that  his  account  ot  his  state  when  he  has  recovered  from 
the  drug  is  not  wholly  fictitious. 

The  drug,  after  it  has  allayed  his  sufferings,  renders  him 
more  acutely  sensitive  to  all  conditions  of  discomfort,  and  this 
morphia  hypersesthesia  is  often  very  pronounced  in  "  abdominal 
cases."  For  this  reason,  again,  the  rule  must  be  observed  of 
giving  as  little  of  the  drug  as  possible.  Moreover,  morphia  in 
large  doses  is  an  ill  preparation  for  an  abdominal  operation. 
It  induces  a  state  of  paralysis  in  the  alimentary  canal.  The 
bowel,  when  relieved  of  the  obstructing  cause,  has  no  power  to 
avail  itself  of  its  freedom,  nor  ability  to  empty  itself  of  its  foul 
contents.  It  remains  lethargic  and  inert  with  dilated  vessels 
and  an  embarrassed  circulation,  and  I  think  that  the  prospect 
of  an  operation  for  acute  intestinal  obstruction  is  much 
marred  if  the  body  at  the  time  is  saturated  with  a  drug 
whose  energies  are  so  marked  by  extremes. 

The  morphia  employed  in  the  hypodermic  injection  should 
always  be  given  in  the  "  tabloid  "  form.  The  tabloid  secures 
an  easy  administration,  and  an  accurate  dose.  The  solution 
of  morphia  is  apt  in  time  to  become  altered  in  strength  by 
concentration  and  to  undergo  certain  chemical  changes  asso- 
ciated with,  it  is  said,  the  production  of  apomorphia. 
Apomorphia  is  well  known  to  be  a  ready  emetic,  a  drug, 
therefore,  which  is  certainly  not  desirable  in  the  cases  now 
under   consideration. 

In  my  opinion  morphia  is  better  employed  if  administered 
alone,  and  I  have  seen  no  advantage  attending  the  use  of  a 
mixture  of  morphia  with  atropia.  The  atropia  is  apt  to  add 
greatly  to  the  sense  of  thirst — which  is  often  of  itself  a  very 
distressing  symptom — and  to  the  painful  dryness  of  the 
mouth. 

3.  The  Evacuation  of  the  Lower  Bowel. — As  soon  as 
the  patient  is  becoming  under  the  influence  of  the  morphia  it 
is  well  to  clear  out  the  lower  bowel  by  means  of  an  enema. 
An  injection  of  salt  and  water  of  the  strength  of  two  drachms 
of  table  salt  to  a  pint  of  warm  water  is  probably  the  most 
efficacious.  I  would  only  say  that  such  evacuation  of  the 
bowel  is  dasirable,  not  that  it  is  absolutely  essential. 

Often  the  colon  is  found  to  be  loaded,  and  the  ridding  of 
the  body  of  the  mass  of  fseces  contained  therein  is  certainly 
most  desirable  ;  often  great  temporary  relief  is  afforded  by  such 
evacuation  of  the  bowel.  In  any  case  undesirable  m^atter  is 
got  rid  of,  and  the  tension  within  the  abdomen  is  diminished. 
It  is  singular  what  great  mental  relief  such  a  clearing  out  of 
the  bowel  will  often  give  to  the  patient,  whose  one  idea  of 
improvement  is  bound  up  in  an  action  of  the  bowel.     More- 


EVACUATION    OF    THE    LOWER    BOWEL.  457 

over,  it"  nutrient  eneniata  are  to  be  administered,  or  if  thirst  is 
to  be  controlled  by  injections  of  water,  or  if  drugs  or  stimulants 
are  to  be  given  by  the  rectum,  it  is  obvious  that  this  part  of 
the  gut  should  be  tirst  emptied  of  its  contents. 

The  treatment  of  intussusception  also  by  rectal  injection, 
or  by  insufflation,  is  certainly  rendered  more  etiicient  if  the 
lower  bowel  has  been  already  emptied. 

The  enema  to  be  effectual  must  be  given  early  in  the  case. 
When  the  patient  is  well  under  the  influence  of  morphia,  or 
when  days  have  elapsed  since  the  onset  of  the  attack  an 
evacuation  of  the  bowel  is  less  to  be  expected.  In  many  cases 
the  enema  produces  no  effect,  no  matter  at  what  period  in  the 
case  it  is  employed.  It  is  very  commonly  returned  without 
alteration,  or  is  retained  entirely,  or  for  an  mdefinite  time. 
Sometimes  it  distinctly  aggravates  the  pain  and  I  have  known 
the  pain  to  be  so  much  increased  by  the  enema  as  to  demand 
an  additional  dose  of  morphia.  Such  ill  results  are,  however, 
more  than  counterbalanced  by  the  occasions  on  which  the 
injection  is  followed  by  a  complete  evacuation  of  the  loaded 
lower  bowel.  The  injection  should  be  small  in  amount  and 
should  be  introduced  without  force.  With  such  precautions 
it  can  at  least  do  no  harm  and  may,  on  the  other  hand,  do 
much  good.  In  view  of  a  possible  operation  I  am  sure  that 
all  surgeons  will  agree  with  the  axiom  that  it  is  well  to  start 
with  an  empty  colon.  There  is  no  object  to  be  gained  in 
repeating  the  enema.  If  it  fails  to  act  the  first  time  it  will 
probably  fail  to  act  on  the  second  occasion,  and  if  its  use  is 
followed  by  an  evacuation  the  purpose  of  the  treatment  has 
been  secured. 

It  is  common,  however,  to  find  that  the  surgeon,  in  response 
to  the  never-ending  prayer  of  the  patient  that  his  bowels  may 
act,  or  under  the  influence  of  doubt  as  to  the  nature  of  the 
obstruction,  has  persisted  in  repeated  injections  once  or  twice 
in  the  day  without  doing  more  than  adding  to  the  patient's 
already  heavy  burden  of  discomforts. 

The  use  of  enemata  in  intussusception  belongs  to  a  method 
of  special  treatment  with  which  the  present  subject  has  no 
concern.  Those  who  have  in  their  minds  a  vivid  conception 
of  the  pathological  conditions  which  underlie  acute  intestinal 
obstruction  (intussusception  being  excepted),  will  appreciate 
that  an  enema  can  have  no  effect  upon  such  an  obstruction 
when  once  declared,  and  can  do  no  more  than  possibly  wash 
away  any  f?ecal  matter  which  may  occupy  the  bowel  below 
the  situation  of  the  block. 

While  dealing  with  this  subject  it  is  perhaps  needless  to 
say.  that  in  no  circumstances  whatever  should  any  aperient 


453  TREATMENT    OF   ACUTE    OBSTRUCTION. 

or  purgative  be  given  in  a  case  of  acute  intestinal  obstruction. 
The  use  of  such  medicines  is  to  be  absolutely  condemned 
without  reservation  of  any  kind.  Let  those  who  have  any 
doubt  upon  this  subject  conceive  the  case  to  be  one  of  a  tight 
strangulation  of  a  coil  of  ileum  by  a  rigid  band,  and  ask  them- 
selves what  eflcct  a  "  brisk  aperient "  is  likely  to  have  upon 
such  a  condition.  It  will  merely  excite  increased  peristaltic 
action,  and  at  once  aggravate  all  the  symptoms.  It  will 
intensify  the  pain,  will  deepen  the  collapse,  will  render  the 
vomiting  more  severe  and  do  the  patient  nothing  but  the 
utmost  amount  of  harm.  I  have  no  doubt  whatever  that  in 
cases  of  lax  snaring  of  the  bowel  an  aperient  may  have  the 
effect,  by  setting  up  increased  peristalsis,  of  making  an 
obstruction,  from  which  the  bowel  might  possibly  free  itself, 
absolute  and  irremediable.  Illustrations  are  not  lacking  of 
the  unfortunate  eftect  of  purgatives  in  acute  obstruction 
because  they  are  not  infrequently  administered  by  the  patient's 
friends  before  the  doctor  is  summoned. 

Fortunately,  in  most  cases  the  aperient  is  at  once  vomited 
when  taken ;  but  when  it  is  retained,  or  when  croton  oil  is 
used,  or  when  the  aperient  drug  is  administered  by  an  enema, 
it  can  only  be  said  that  it  does  unmixed  harm.  In  a  great 
many  instances  the  symptoms  have  not  become  severe  until 
after  the  administration  of  a  purge.  Vomiting  that  had  been 
moderate  and  merely  bilious  has  become  profuse  and  stercor- 
aceous  after  the  use  of  an  aperient.  Profound  collapse,  with 
sudden  intense  pain,  has  also  followed  this  treatment,  and  it 
has,  in  many  instances,  I  am  convinced,  brought  about  a 
threatening  perforation  of  the  bowel.  Aperient  medicines  in 
these  maladies  have  rendered  subacute  cases  acute,  and  have 
caused  even  chronic  forms  of  obstruction  to  take  on  an  acute 
development.  Indeed,  among  the  indirect  causes  of  death  in 
"  stoppage  of  the  bowels  "  purges  would  occupy  a  very  promi- 
nent position,  if  all  the  cases  where  they  have  been  used  could 
be  brought  to  light.  The  evil  effects  of  aperients  in  cases  allied 
to  those  now  under  notice  is  shown  in  an  instance  of  injury  to 
the  abdomen  reported  by  Mr.  Sinion."^  A  man,  aged  sixty, 
was  ridden  over,  and,  as  an  autopsy  showed,  his  jejunum  was 
partially  ruptured.  No  extravasation,  however,  appears  to 
have  taken  place  at  or  immediately  after  the  accident.  For 
seventy  hours  the  patient  remained  free  from  any  symptom  of 
abdominal  trouble.  He  had  then  several  doses  of  aperient 
iTiedicine.  Symptoms  of  perforative  peritonitis  very  rapidly 
developed,  and  the  patient  died.  In  this  case  death  may  be 
fairly  ascribed  to  the  effect  of  the  treatment. 

*  Path.  Soc.  Trans.,  vol.  iv.;  1853,  p.  151. 


THE    QUESTION    OF    FEEDING.  459 

In  acute  and  subacute  I'onns  of  intussusception,  also, 
aperients  can  do  nothing  but  harin.  They  simply  excite  in- 
creased peristaltic  movement  and  greatly  aggravate  the  local 
condition.  In  not  a  tew  instances  that  have  been  reported  the 
use  of  an  aperient  has  evidently  determined  the  strangulation 
of  an  intussusception,  and  has  hopelessly  compromised  the 
prospects  of  the  case. 

In  volvulus  of  the  sigmoid  flexure  and  of  other  parts  it  is 
needless  to  say  that  aperients  not  only  do  inlinite  harm,  but 
also  tend  to  increase  and  not  to  diminish  the  distortion  of 
the  bowel. 

The  question  of  aperients  in  acute  intestinal  obstruction 
often  brings  the  practitioner  into  conflict  with  the  patient's 
i'r lends  on  the  subject  of  treatment.  As  soon  as  the  case  is 
declared  to  be  one  of  obstruction  of  the  bowels  there  are  not 
a  few — even  among  the  educated — who  consider  that  such  an 
obstiii;tion  can  only  be  dealt  with  by  aperients,  and  who 
decline  to  gauge  the  progress  of  the  case  except  by  what 
passes  from  the  rectum. 

To  such  individuals  a  cathartic  is  the  only  "  means  of 
grace."  I  have  known  the  friends  of  patients  who  have  been 
possessed  with  this  creed  to  administer  secretly  to  the  sick 
man  some  special  aperient  of  their  own,  or  some  subtle  and 
much  advertised  pills,  which,  according  to  printed  testinjonials, 
have  sa,ved  many  hopeless  persons  from  the  grave.  It  is  a 
happy  circumstance,  in  connection  with  such  imenlightened 
measures,  that  a  prominent  symptom  of  acute  intestinal 
obstruction  is  vonnting. 

4.  The  Question  of  Feeding-. — In  dealing  with  acute 
intestinal  obstruction  it  may  be  said,  in  general  terms,  that  the 
question  of  feeding  does  not  arise.  The  patient  should  be 
starved,  not  fed.  In  a  typical  acute  case  nature's  distinct  effort 
is  to  relieve  the  patient  by  emptying  his  alimentary  canal.  If 
he  dies,  his  death  will  most  probably  be  due  to  the  absorption 
of  poisonous  material  from  the  loaded  bowel. 

It  is  a  pressing  matter,  therefore,  that  the  canal  should  be 
emptied.  The  contents  of  the  gut  cannot  pass  downwards 
owing  to  ihe  obstruction  in  its  lumen.  They  pass  upwards  and 
pour  themselves  into  the  stomach.  The  patient  vomits,  the 
vomiting  is  copious  and  incessant,  and  the  vomited  matter  is 
represented  at  last  by  the  foul  and  decomposed  contents  of 
the  disturbed  bowel.  It  is  well  that  the  patient  should  be 
rid  of  this,  for  the  one  great  danger  which  threatens  him  is 
self-poisoning  from  his  own  bowel. 

There  is  some  purpose  in  "  symptoms,"  and  many  of  the 
phenomena  of  disease  are  expressions  of  attempts  at  affording 


460  TREATMENT    OF    ACUTE    OBSTRUCTION. 

relief.  If  nature's  indications  are  to  be  followed,  the  hint  given 
in  acute  intestinal  obstruction  is  that  the  alimentary  canal 
should  be  emptied,  and  not  filled.  The  patient  is  decidedly 
not  relieved  by  putting  food  into  his  stomach,  but  he  is  for  a 
time  greatly  relieved  by  the  emptying  of  his  stomach  by 
washing  it  out. 

Apart  from  any  general  considerations  it  is  obvious  that  it 
is  worse  than  useless  to  attempt  to  feed  these  patients  by  the 
mouth.  The  patient  is  very  sick  ;  he  not  only  vomits  every- 
thing that  he  takes,  but  will  vomit  at  other  times  than  after 
the  ingestion  of  food.  In  many  subacute  cases,  where  the 
sickness  is  not  so  marked,  the  taking  of  nourishment  excites 
the  act  of  vomiting  after  the  symptom  has  abated,  and  the 
patient  may  for  a  while  be  only  sick  after  he  has  taken  food. 

There  is  usually  an  entire  lack  of  appetite,  and  a  disgust  of 
food,  quite  apart  from  the  circumstance  that  every  mouthful 
swallowed  is  apt  to  aggravate  one  of  the  most  distressing  of  the 
symptoms.  Moreover,  even  if  it  be  supposed  that  the  food 
can  be  retained,  it  is  scarcely  possible  to  imagine  that  it  can 
be  digested  and  absorbed.  The  stomach  is  not  improbably 
occupied  by  matters  regurgitated  from  the  bowel.  The  small 
intestine  above  the  obstruction  is  more  or  less  congested,  is 
distended,  is  occupied  by  putrefying  contents,  and  is  certainly 
not  in  a  condition  further  to  elaborate  or  even  to  absorb  any 
food  matters  that  may  reach  it  from  the  stomach. 

There  is  still  one  other  aspect  of  the  question.  In  some 
cases  of  acute  intussusception,  food  may  occasionally  be 
swallowed  w^ithout  causing  sickness.  That  such  food  is 
digested  and  absorbed  is  not  very  probable.  Whether  it  is  or 
not  is  a  little  apart  from  the  question,  since  clinical  experience 
shows  that  the  matters  if  not  rejected,  will  excite  increased 
peristaltic  action  in  the  intestines,  and  will  decidedly  aggra- 
vate the  condition  of  the  invagination.  It  is  obvious,  there- 
fore, that  if  food  is  to  be  administered  in  these  cases,  it  must 
not  be  administered  by  the  mouth.  Inasmuch  as  any  food 
taken  is,  almost  Avithout  exception,  rejected  by  vomiting,  and 
is,  if  retained,  made  no  use  of  by  the  patient,  it  is  desirable, 
in  cases  of  acute  intestinal  obstruction,  entirely  to  abandon 
feeding  by  the  mouth. 

Three  minor  questions  remain  to  be  considered : — 

1.  If  the  patient  is  not  vomiting,  may  he  take  food  ? 

2.  How  is  the  strength  of  the  patient  to  be  maintained 
without  food  ?  and 

3.  How  is  the  intolerable  thirst  to  be  relieved  ? 

1.  If  not  vomiting  may  food  he  taken? — In  certain  cases 
the  vomiting  is  not  marked,  and  in  patients  who  are  well 


THE    QUESTION    OF   FEEDING.  461 

ander  the  intiuence  of  morphia  that  symptom  may  be,  for  a 
while  at  least,  in  abeyance. 

In  such  exceptional  instances  food  may  be  given  by  the 
mouth,  but  it  nmst  be  administered  in  very  minute  quantities 
and  be  given  rather  to  meet  the  sentiment  of  the  case,  or  to 
relieve  the  distressing  symptom  of  thirst. 

The  patient  himself  feels  that  he  must  be  taking  some- 
thing to  "  keep  up  his  strength,"  and  there  is  an  overwhelming 
prejudice  among  those  who  practise  domestic  nursing  in 
favour  of  constantly  plying  the  sick  with  food.  All  sorts  of 
messes  are  prepared  by  the  anxious  mother  or  the  distracted 
wife,  which  have  the  reputation  of  being  "  supporting "  and 
the  forcing  of  these  upon  the  sick  man  relieves  the  intense 
desire  to  be  doing  something.  Oysters  and  other  delicacies 
appear  upon  the  scene,  turtle  soup  is  sent  for  and  obtained 
in  circumstances,  perhaps,  of  heroic  difficulty ;  beef-tea 
"  which  is  quite  a  jelly  when  cold,  and  in  which  a  spoon  will 
stand  upright "  is  introduced  by  some  over-impulsive  relative 
who  has  a  reputation — probably  well  deserved — of  being 
"  wonderful  in  cases  of  sickness."  All  these  efforts  are  the 
expressions  of  a  natural  anxiety  which  must  have  some  vent 
for  its  eagerness  and  activity,  and  if  only  the  patient  can 
swallow  a  tea  spoonful  some  watcher  at  the  bedside  is  made 
happy  for  the  moment.  The  patient,  moreover,  has  often  a 
morbid  appetite  and  begs  for  a  glass  of  beer,  or  for  some 
cherished  cordial,  or  for  a  lemon  or  a  sponge-cake.  Against 
all  these  abnormal  tendencies  the  surgeon  must  set  his  face 
with  suitable  sympathy  and  appropriate  argument. 

The  patient  may  take  hot  water  in  doses  of  one  drachm  to 
half  an  ounce,  or  may  replace  this  by  equal  quantities  of  hot 
weak  tea.  The  fluid  must  not  be  warm  but  must  be  as  hot  as 
can  be  taken.  Now  and  then  a  little  hot,  sterilised  milk  may 
be  given,  or  a  little  jelly  as  a  palliative  to  the  feelings  of  the 
friends,  but  beyond  this  it  is  not  safe  to  go.  I  have  met  with 
a  few  instances  in  which  food  in  larger  quantity  and  of  more 
substantial  quality  has  been  taken  without  discomfort,  and 
have  seen  an  instance  in  which  an  infant  with  acute  intussus- 
ception took  the  breast  without  vomiting  from  the  commence- 
ment of  the  case  until  relief  was  attordea  by  operation.  It  is 
in  cases  of  intussusception  occasionally  that  quite  a  quantity 
of  fluid  may  be  taken  by  the  mouth  without  apparent  incon- 
venience. It  may  be  argued  that  as  an  operation  is  almost 
certainly  pending,  such  indulgence  may  be  excused,  especially 
as  Avhat  is  taken  is  very  nearly  certain  to  be  rejected  in  time 
by  vomiting.  Such  an  argument,  however,  is  not  a  valid  one. 
The  object  is  to  get  matter  out  of  the  stomach  and  not  to  put 


462  TREATMENT    OF   ACUTE    OBSTRUGTION. 

more  into  it.  It  is  doubtful  if  anything  that  is  taken  is 
made  use  of,  and  if  even  the  water  which  is  swallowed  is 
absorbed. 

If  some  relaxation  of  the  rule  of  starvation  be  observed  in 
cases  in  which  food  can  be  taken,  it  should  not  go  beyond  the 
very  narrow  limits  indicated,  and  should  be  regarded  rather  as 
a  matter  of  policy  than  as  a  question  of  right  treatment. 

On  no  account  should  beef-tea,  or  meat  juices,  or  meat 
extracts  be  given.  The  patient  can  certainly  not  dispose  of 
these.  They  merely  add  more  material  to  the  slough  of 
decomposing  fluid  with  which  the  upper  part  of  the  alimentary 
canal  is  already  only  too  full  and  add  wofully  to  his  embarrass- 
ments. 

Objection  is  also  to  be  taken  to  brandy  or  to  champagne 
administered  by  the  mouth.  If  a  stimulant  be  needed  it  can 
be  given  in  other  and  more  efficient  ways,  and  I  have  noticed 
that  stimulants  taken  b}'  the  mouth  are  apt  to  engender  a 
filthiness  of  the  mouth  of  which  the  patient  soon  complains. 
Unfortunately  there  is  always  someone  at  hand  who  has  access 
to  brand}'  of  remarkable  age  and  power,  or  who  shares  the 
quite  common  belief  that  no  sick  man  in  a  civilised  country 
should  be  allowed  either  to  recover  or  to  die  without  taking 
champagne. 

As  to  the  sucking  of  ice  I  liave  only  to  say  that  in  my 
opinion  the  practice  is  to  be  condemned  without  reservation. 
When  the  first  edition  of  this  book  was  written  it  was  the 
custom  to  advise  the  use  of  ice  in  these  cases. 

I  have  seen  a  good  deal  of  this  little  item  of  treatment 
and  have  learnt  to  condemn  it  absolutely.  It  introduces  an 
unknown  quantity  of  cold  fluid  into  the  stomach  of  a  patient 
who  is  already  probably  not  quite  recovered  from  collapse,  and 
the  readiness  with  which  it  is  returned,  and  the  manifest  dis- 
comfort it  occasionally  induces,  leads  one  to  think  that  it  is  a 
measure  which  might  well  be  allowed  to  be  forgotten. 

The  rule,  therefore,  should  remain  that  the  patient  with 
acute  intestinal  obstruction  should  take  absolutely  nothing  by 
the  mouth,  except  possibly  a  little  hot  water  or  a  little  liot 
weak  tea,  but  even  of  these  the  less  the  better. 

I  have,  so  far,  been  considering  really  acute  cases.  In  sub- 
acute cases  the  rule  as  to  starvation  may  be  relaxed  with 
discretion,  and  in  instances  of  subacute  intussusception  this 
relaxation  may  proceed  to  some  degree.  Still  here,  however, 
the  observation  remains  good,  that  it  is  useless  to  introduce 
food  into  the  stomach  of  an  individual  who  persists  in  vomit- 
ing.    If  vomiting  continues  all  food  must  be  discontinued. 

2.  How  is  the  strength  to  he  maintained? — The  question 


THE    QUESTION    OF   FEEDTNG.  463 

as  to  the  maintenance  of  the  patient's  strength  is  one  rather 
which  concerns  the  friends  of  the  patient  than  the  patient 
himself,  as  it  is  from  them  that  the  question — tediously 
repeated — usually  comes. 

In  the  abstract  it  is  desirable  that  the  patient's  strength  be 
maintained,  but  this  is  not  effected  by  introducing  food  into  a 
stomach  which  will  not  retain  it,  or  which  will  not  make  use 
of  it  if  it  be  retained.  It  is  well  to  remember  how  long  the 
human  being  can  go  without  food  without  any  disastrous 
results,  so  long  as  he  be  supplied  with  fluid. 

The  possibilities  in  this  direction  have  been  illustrated  by 
well  authenticated  accounts  of  imprisoned  miners  who  have 
been  kept  entirely  without  any  food,  except  water,  for  seven 
or  more  days,  and  who,  when  liberated,  have  walked  with  no 
uncertain  step.  In  most  examples  of  really  acute  obstruction 
the  progress  of  the  case  is  so  rapid  that  the  question  of 
supporting  the  patient  by  food  does  not  require  to  be  enter- 
tained. The  s}'mptoms  are  often  ended  by  death  or  are 
relieved  by  operation  before  the  problem  of  maintaining  the 
patient's  powers  by  food  need  even  be  considered.  In  the 
frankly  acute  case  the  forcing  of  nourishment  into  the  stomach 
does,  without  doubt,  very  much  more  harm  than  good. 

In  subacute  cases  the  question  of  feeding  does  obtain  a 
certain  degree  of  importance.  Now  and  then,  in  cases  which 
are  long  extended,  there  is  little  doubt  but  that  one  of  the 
factors  in  the  exhaustion  which  leads  to  death  depends  upon 
the  patient's  inability  to  take  or  to  retain  food. 

A  long  enforced  abstinence  from  food  renders  the  body,  no 
doubt,  less  able  to  resist  the  toxic  influences  which  are  spread- 
ing from  the  disordered  bowel  and  modifles  injuriously  the 
result  of  any  operation.  In  certain  instances  of  intussuscep- 
tion a  process  of  spontaneous  relief  has  been  found  to  be 
nearly  complete  at  the  time  of  death,  and  to  have  been 
arrested  by  a  fatal  exhaustion  which,  although  often  due  to 
septicEemia,  may  certainly  have  been  encouraged  by  an 
inability  to  take  food. 

It  is  in  the  subacute  cases,  then,  that  an  attempt  at  feed- 
ing may  be  made  with  caution.  If  there  be  no  vomiting- 
some  feeding  by  the  mouth  may  be  attempted,  and  even  in 
cases  in  which  there  is  some  vomiting  a  certain  amount  of 
food  may  be  retained  by  the  stomach  if  that  viscus  be 
periodically  evacuated  by  washing  out. 

If  vomiting  be  persisting  feeding  by  the  mouth  is  abso- 
lutely contra-indicated. 

In  the  cases  under  consideration  rectal  feeding  may  be 
resorted  to.     Enemata  composed  of  one  ounce  and  a  half  of 


464  TREATMENT    OF   ACUTE    OBSTRUCTION. 

peptonised  beef-tea  with  half  an  ounce  of  brandy,  given  every 
three  or  four  hours,  appear  to  answer  as  well  as  do  most  of 
such  injections.  In  any  case  the  rectum  must  be  washed  out 
daily  with  warm  water. 

The  question  of  rectal  feeding  is  further  dealt  with  in  a 
later  chapter  (page  524).  Other  enemata  are  composed  of 
peptonised  milk,  pancreatised  meat,  peptones,  or  other  of  the 
numerous  substances  advised  for  this  method  of  feeding. 

Personally  I  am  not  so  impressed  with  the  value  of  rectal 
feeding  as  are  some.  Those  who  are  strong  in  its  advocacy 
are  a  little  unmindful  of  the  remarkable  length  of  time  dur- 
ing which  a  human  being  lying  motionless  in  bed  can  do 
without  food  if  only  the  proper  amount  of  Huid  be  introduced 
into  the  body. 

When  cases  are  reported  to  show  how  long  an  individual 
has  been  kept  alive  by  nutrient  enemata  I  am  disposed  to 
think  that  the  interest  of  such  cases  tends  rather  to  demon- 
strate how  long  a  man  can  go  without  nourishment  of  any 
kind  except  water. 

That  the  fluid  part  of  the  nutrient  enema  is  absorbed 
admits  of  no  doubt,  and  if  a  stimulant  be  embodied  in  the 
injection  its  effect  upon  the  patient  is  unquestionable.  The 
same  may  be  said  of  most  soluble  drugs  (for  example, 
laudanum)  which  are,  for  one  purpose  or  another,  introduced 
into  the  bowel. 

But  whether  the  solid  part  of  the  enema  is  digested, 
absorbed,  and  made  use  of  as  food  is  a  matter  upon  which  a 
legitimate  difference  of  opinion  may  still  be  permitted.  I  am 
especially  disposed  to  be  sceptical  about  the  nutrient  sup- 
pository. I  have  been  much  struck  with  the  quantity  of 
material  which  can  be  washed  out  of  the  rectum  of  patients 
who  are  being  fed  on  nutrient  enemata  and  suppositories, 
and  I  am  a  little  disposed  to  ask  if  the  quantity  of  solid 
matter  returned  by  such  washing  out  of  the  gut  is  much 
less  than  the  amount  of  solid  matter  introduced. 

As  in  the  majority  of  examples  of  acute  obstruction  the 
small  intestine  is  involved,  nutrient  enemata  are  for  the 
most  part  well  retained.  Sometimes  they  cause  pain  and 
distress  and  have  to  be  discontinued. 

In  cases  of  volvulus  of  the  sigmoid  flexure  nutrient 
enemata  are  seldom  retained,  and  I  think  it  will  be  found 
that  they  are  usually  either  rejected  or  are  unabsorbed  in 
instances  in  which  the  rectum  is  ballooned. 

There  are  other  circumstances  besides  these  in  Avhich 
the  administration  of  food  by  enemata  is  not  possible.  In 
many  examples  of  intussusception  it   is  not  possible.     The 


77/7*;    Q,UESTIO\'    OF    Fh'J'JDlNQ.  -465 

invagination  has  reached  the  lower  colon,  there  is  tenesmus, 
the  contents  of  the  bowel  are  being  frequently  rejected  by 
a  species  of  diarrhoea,  and  enernata  merely  aggravate  the 
peristaltic  movements  of  the  tube.  In  these  cases,  however, 
that  are  associated  with  diarrhoea,  there  is  often  compara- 
tively little  vomiting,  and  the  patient  is  not  infrequently 
able  to  take  a  little  nourishment  by  the  mouth  without 
inconvenience  being  caused. 

There  are  other  cases  of  obstruction  apart  from  intussus- 
ception, where  the  administration  of  enemata  is  undesirable 
on  account  of  the  disturbance  produced,  the  mere  injection 
having  caused  in  such  instances  an  increase  in  the  vomiting, 
and  in  the  pain  depending  upon  peristaltic  movements. 

One  nmst,  in  concluding  this  part  of  the  subject,  still 
return  to  the  proposition  that  in  acute  intestinal  obstruction 
the  question  of  maintaining  the  patient's  strength  by  food 
does  not  arise,  and  in  subacute  cases  it  rarely  assumes  a 
pressing  position.  The  treatment  of  these  conditions  is 
by  immediate  operation,  and  if  the  food  question  has  come 
to  be  considered  there  must  be — in  any  instance  in  which 
the  diagnosis  is  undoubted — a  suggestion  that  the  proper 
treatment  is  being  unnecessarily  delayed. 

In  certain  of  the  acute  and  subacute  cases  there  may  be  a 
doubt  as  to  the  real  nature  of  the  condition,  and  in  the  latter 
type  of  case  there  may  be  a  history  of  recovery  from  a  pre- 
cisely similar  attack.  In  such  circumstances  delay  may 
be  occasionally  justifiable,  and  the  question  of  feeding  may 
then  come  to  the  front. 

3.  Hoiv  is  the  intolevahle  thirt  to  be  relieved? — This 
symptom  is  best  treated  by  an  occasional  enema  of  warm 
water.  The  amount  administered  is  half  a  pint,  and 
the  temperature  of  the  fluid  is  about  99*^  F.  Asa  rule 
the  injection,  if  repeated  every  three  or  four  hours,  will 
almost  entirely  relieve  this  distressing  symptom. 

In  the  place  of  plain  water  some  advise  an  enema  of 
the  physiological  salt  solution. 

The  patient  may  be  allowed  to  rinse  the  mouth  out 
with  cold  water  as  often  as  he  thinks  well. 

Much  complaint  is  made  of  the  foul  taste  in  the  mouth 
and  of  the  dryness  of  the  tongue.  These  conditions  are  met 
by  keeping  the  mouth  very  clean,  by  the  frequent  use  of  the 
tooth  brush,  by  the  employment  of  a  mouth  wash  such  as 
one  composed  of  I  in  80  solution  of  carbolic  acid,  or  of  a 
mixture  of  eau  de  cologne  and  water.  There  is  no  harm 
in  allowing  the  patient  now  and  then  to  chew  a  minute 
piece  of  lemon. 

E  E 


466  TREATMENT    OF   ACUTE    OBSTRUCTION. 

If  the  tongue  be  dry,  the  discomfort  which  it  occasions 
may  be  reheved  by  occasionally  painting  it  over  with  boro- 
glyceride  and  water. 

In  cases  in  which  the  thirst  is  maddening  and  the  craving 
for  a  "  big  drink "  intolerable,  I  have  seen  no  harm  now  and 
then  in  allowing  the  patient  to  take  a  coj)ious  draught  oi 
fluid,  to  the  amount  of  a  pint  or  less.  This  should  be  hot, 
if  possible.  The  fluid  so  taken  is  almost  immediately  rejected, 
but  it  serves  to  wash  out  the  stomach,  and  makes  the 
patient  for  a  while,  at  least,  more  comfortable  and  more 
contented. 

Curschmann  says  that  thirst  may  be  relieved  by  sub- 
cutaneous injections  of  saline  solutions,  but  I  have  not  found 
this  measure  so  successful  as  the  enemata  of  warm  water. 

No  evidence  has  been  induced  in  favour  of  intravenous 
injections  as  a  means  of  allaying  intense  thirst. 

5.  The  Use  of  Measures  other  than  Operation.— These 
measures — which  are  quite  numerous — call  for  very  little 
comment.  They  are  for  the  most  part  feeble  excuses  for 
avoiding  or  delaying  an  operation.  Previous  to  the  intro- 
duction of  antiseptic  surgery  there  may  have  been  an  excuse 
for  their  employment  which  they  no  longer  can  present. 
They  may  be  roughly  divided  into  three  categories,  viz.  those 
which  are  absolutely  harmful,  those  which  are  probably 
harmless  but  inert,  and  those  which  contain  some  element 
of  distinct  therapeutic  value. 

Among  those  measures  which  may  be  condemned  as 
harmful  are  massage  of  the  abdomen  and  abdominal  taxis, 
including,  if  need  be,  the  inversion  of  the  body. 

When  a  coil  of  bowel  is  strangulated  within  the  abdomen 
and  is  becoming  gangrenous,  or  when  it  has  become  bloodless 
from  extreme  torsion,  or  when  it  has  become  invaginated,  it 
may  well  be  asked  what  other  effect  than  harm  can  come 
from  massage  of  the  abdomen.  Such  manipulation  may 
stimulate  peristalsis  and  increase  the  gravity  of  the  condi- 
tion, or  it  may  rupture  an  already  moribund  bowel,  or  make 
effective  a  threatened  perforation.  Those  who  are  familiar 
with  the  operation  of  laparotomy  for  acute  intestinal  obstruc- 
tion will  realise  the  delicacy  Avith  which  the  distended  bowel 
has  to  be  handled,  and  the  terrible  ease  with  which  the  tense 
peritoneal  coat  is  torn ;  they  will  also  have  made  themselves 
familiar  with  the  difiiculty  which  attends  the  liberation  of 
a  snared  loop  or  the  reduction  of  an  invagination  even  when 
the  parts  are  well  exposed  and  are  under  the  fingers.  Those 
who  have  most  experience  of  these  conditions  are  fully 
conscious  that  nothing  save  disaster  is  likely  to   follow  the 


OTHER    MEASURES    THAN"   OPERATION.  4G7 

pummelling  and  rubbing  anrl  compression  of  the  abdomen 
by  a  rubber. 

Massage  has  indeed  been  frequently  used  in  cases  of  intus- 
susception. I  can,  however,  find  no  case  where  cure  can  be 
said  to  have  followed  this  treatment  alone.  In  the  cases 
of  reputed  cure  the  massage  was  usually  subsequent  to,  or 
coincident  with,  the  administration  of  copious  enemata,"^ 
and  the  morbid  anatomy  of  invagination  would  lead  us 
to  suppose  that  the  injection  would  have  more  effect  than 
the  manipulation. 

In  several  of  the  reputed  examples  of  cure  by  massage 
other  modes  of  treatment  had  been  adopted  to  which  some 
share  in  the  cure  may  possibly  be  ascribed.  This  is  well 
illustrated  in  a  remarkable  case  reported  by  M.  Bitterlin.  The 
patient,  a  man  aged  fifty-six,  w^as  seized  with  symptoms  of 
acute  intestinal  obstruction.  The  obstruction  lasted  ten  days 
and  the  symptoms  were  very  severe.  During  these  ten  days 
the  following  therapeutic  measures  were  adopted  for  the 
relief  of  the  unfortunate  patient.  Morphia  was  administered, 
followed  by  large  doses  of  castor-oil,  and  subsequently  by  large 
doses  of  croton-oil.  Enemata  of  water,  of  senna,  of  sulphate 
of  magnesia,  and  of  tobacco  were  injected  at  different  times. 
Poultices  were  first  of  all  applied  to  the  abdomen,  and  these 
were  in  time  followed  by  frictions  with  belladonna.  Electricity 
was  used.  All  these  means  were  without  effect.  At  last 
massage  was  tried,  an  almost  immediate  relief  followed,  and 
the  patient  recovered  in  spite  of  treatment.t 

It  is  only  fair  to  say  that  massage  has  been  used  with  good 
effect  in  some  acute  cases  of  obstruction  by  gall  stones.  In 
these  cases  the  manipulation  of  the  abdomen  probably  not 
only  excites  peristaltic  movement  but  also  directly  dislodges 
the  obstructing  matter.  As  an  illustration  may  be  cited  a  case 
reported  by  Martin.  The  patient,  a  woman  aged  seventy- 
eight,  was  suffering  from  symptoms  of  severe  obstruction  due 
to  the  impaction,  probably  in  the  terminal  part  of  the  ileum, 
of  a  large  gall  stone.  Aperients  had  had  no  effect  and  the 
vomiting  had  become  stercoraceous.  A  tumour  could  be 
detected  in  the  right  iliac  fossa.  On  the  sixth  day  massage 
was  employed ;  relief  followed,  and  on  the  next  day  a  large 
gall  stone  and  ten  smaller  stones  were  evacuated.! 

"  Abdominal  taxis "  is  a  term  which  covers  a  greater 
departure  from  rational  treatment  and  involves  in  the  hands 
of  some  manipulations  and  movements  which,  but  for  their 

*  See  case  bv  Dr.  Gillette,  Neir  York  Jled.  Journ.,  1882,  p.  261. 

t  r  Union  Medicaid  1882,  p.  4.S3. 

X  Bull,  de  la  Soc.  Anat.  de  Paris,  1875,  p.  195, 


468  TEEATMENT    OF   ACUTE    OBSTIiUCTIOK 

iniquity,  would  merely  be  termed  stupid.  These  extreme  and 
blindly  applied  measures  of  treatment  belong  to  the  Dark 
Ages,  and  in  efficacy  and  reason  must  rank  little  above  the 
"  faith  cure  "  of  the  modern  miracle  worker,  and  the  incanta- 
tions of  the  Indian  medicine  man. 

Among  measures  which  may  be  classed  as  harmless  are 
the  methods  of  treatment  by  warm  applications  and  by  ice 
and  possibly  the  treatment  by  electricity.  A  warm  application 
to  the  abdomen  is  often  employed  and  is  often  very  agreeable 
to  the  patient.  If  it  gives  him  any  kind  of  relief  there  is  no 
substantial  argument  against  its  employment.  It  satisfies  in 
a  harmless  Avay  the  craving  for  something  to  be  done. 

The  application  of  ice  to  the  abdomen,  as  advised  by 
Priessnitz  and  others  in  certain  cases,  has,  I  think,  little 
to  commend  it.  The  ice  is  applied  to  the  surface  of  the 
abdomen  in  bags,  or  the  surface  is  cooled  to  the  desired 
temperature  by  means  of  Leiter's  tubes. 

This  measure  of  treatment  is  probabl}^  based  upon  the 
treatment  of  irreducible  or  strangulated  hernia  by  ice-bags. 
So  far  as  the  efficacy  of  a  local  application  is  concerned  the 
two  conditions  are,  however,  not  comparable.  The  patient  in 
acute  intestinal  obstruction  is  often  a  little  collapsed,  and 
ver}^  much  resents  anj^  cold  application  to  the  belly.  One 
would  have  thought  it  not  improbable  that  the  emptying 
of  the  surface  vessels  of  the  abdomen  by  cold  would  merely 
have  added  to  the  engorgement  already  existing  within. 

In  what  is  known  as  "  Grissolle's  method  "  the  use  of  cold 
is  more  extensively  adopted,  and  the  method  professes  to 
be  not  merely  palliative,  but  also  curative.  In  this  procedure 
the  patient  is  encouraged  to  take  as  much  ice  by  the  mouth 
as  possible ;  ice  is  at  the  same  time  freely  applied  to  the 
surface  of  the  abdomen,  and  enemata  of  iced  water  are 
administered  at  frequent  intervals.  The  precise  modus 
operandi  of  Grissolle's  method  in  cases  of  internal  stran- 
gulation is  not  quite  evident,  and  I  can  find  no  definite 
account  of  any  instance  where  cure  can  be  said  to  have 
followed  this  heroic  plan  oi  treatment.  There  are  probably 
many  who  would  not  rank  this  method  of  treatment  as 
harmless. 

The  treatment  by  electricity— which  is  occasionally  advised 
in  acute  cases — may  also  not  always  be  classed  as  useless  but 
harmless. 

It  is  very  difficult  to  understand  how  electricity  can  have 
the  least  curative  effect  in  acute  strangulation  due  to  bands 
or  through  slits  and  apertures.  If  it  acts  by  increasing 
peristaltic   movements,    then   its  use   in   cases  of  this  kind 


OTHER    MEASURES    THAN   OPERATION.  t69 

would  appear  to  be  peculiarly  undesirable.  The  same  obser- 
vations apply  to  acute  or  subacute  intussusception  and  to 
volvulus.  In  these  affections  a  moderation  of  intestinal 
movements  is  a  condition  to  be  desired,  and  if  the  main 
effect  of  electricity  is  to  stimulate  those  movements,  then 
the  measure  must  do  harm  rather  than  good. 

Some  examples  of  supposed  cure  are,  I  think,  a  little 
fanciful.  The  following  may  serve  as  an  instance :  "  Dr. 
Clemens,  of  Frankfort,  states  that  he  has  successfully  treated 
invagination  by  first  administering  one  or  two  tablespoonfuls 
of  metallic  mercury,  which  settled  down  to  the  seat  of  the 
invagination.  The  negative  electrode  was  applied  over  the 
supposed  seat  of  the  disease  and  the  positive  in  the  rectum. 
Voltaic  alternatives  were  used."*  In  connection  with  this 
case  I  might  point  out  that  post-mortem  examinations  do 
not  support  the  belief  that  metallic  mercury,  when  taken 
by  the  mouth,  will  arrange  itself  above  an  invagination,  as 
here  described.     {See  page  554.) 

There  have  been  a  few  cases  reported  of  internal  strangu- 
lation where  electricity  gave  some  slight  temporary  relief 
without,  however,  affecting  the  actual  obstruction.  Thus, 
M.  Terrier  records  the  case  of  a  woman,  aged  twenty-oue,  who 
was  suffering  from  strangulation  of  a  portion  of  the  intestine 
beneath  a  band  connected  with  the  broad  ligament.  On 
the  third  day  electricity  was  used,  and  is  said  to  have 
relieved  the  pain  and  to  have  moderated  the  vomiting. 
The  symptoms,  however,  persisted,  and  laparotomy  was  per- 
formed on  the  fourth  day  with  success.f 

The  methods  of  treatment  now  under  discussion,  for 
which  some  definite  value  under  certain  conditions  can 
be  claimed,  are  the  washing  out  of  tJte  stomach  and  tJte 
puncture  of  the  intestine.  I  have  not,  in  this  place, 
considered  the  treatment  of  intussusception  by  enemata 
or  insufflation.  That  valuable  procedure  is  dealt  with 
under  the  heading  of  operation  (page  501). 

Washing  out  of  the  stomach  gives  very  marked,  and, 
indeed,  often  very  remarkable  relief.  It  is  especially  to  be 
recommended  when  the  vomiting  is  copious  and  distressing, 
and  particularly  when  it  is  stercoraceous. 

The  process  must  be  conducted  very  slowly  and  with  great 
care.  The  patient  should  be  brought  close  to  the  edge  of 
the  bed,  and  should  be  well  propped  up  in  a  sitting  position. 
A  soft  stomach-tube  is  used,  is  well  warmed,  and  is  passed 

*  Medical  and  Surgical  Electricity,  by  Beard  and  Rockwell,  p.  484.  New 
York,  1-871. 

t  Bull,  ct  Mein.  de  la  Soc.  de  Chir.  de  Paris,  1879,  p.  -564. 


470  TREATMENT    OF   ACUTE    OBSTRUCTION. 

slowlj.  It  is  guided  into  the  gullet  by  tlie  groove  formed 
by  two  extended  fingers  placed  upon  the  tongue.  The  head 
must  be  straight  and  the  chin  raised.  The  fluid  employed 
is  hot  water  or  a  hot  salt  solution.  It  is  introduced  by 
means  of  a  glass  funnel,  and  is  removed  by  a  syphon  action. 

The  washing  out  should  be  persevered  with  until  the 
fluid  returns  quite  clear. 

As  will  be  mentioned  subsequently,  this  treatment  is 
especially  to  be  advised  immediately  before  the  patient  is 
anaesthetised  preparatory  to  an  operation. 

As  already  stated,  the  effect  usually  is  very  admirable. 
In  some  cases,  however,  but  little  fluid  is  removed.  In  other 
instances  such  violent  retching  and  distress  are  produced, 
or  such  alarm  is  occasioned,  that  the  treatment  has  to  be 
abandoned.  For  the  latter  reason  it  can  but  seldom  be  adopted 
in  the  cases  of  children.  Considering  the  noxious  and  septic 
character  of  the  material  which  usually  occupies  the  stomach 
in  acute  obstruction,  the  treatment  under  discussion  has 
much  to  recommend  it.  It  not  only  empties  the  stomach, 
but  it  relieves  the  state  of  tension  within  the  abdomen  and 
helps  to  empty  the  upper  part  of  the  small  intestine  by 
encouraging  the  over-full  bowel  to  once  more  pour  its  putrid 
contents  into  the  stomach,  whence  they  can  be  removed. 

It  certainly  also  tends  to  relieve  the  pain,  and  to  improve 
the  pulse  and  general  condition. 

The  measure  is,  of  course,  attended  with  the  best  results 
when  the  obstruction  occupies  the  small  intestine,  and  es- 
pecially when  it  is  located  high  up  in  that  bowel.  When 
it  gives  relief  it  may  be  advantageously  repeated  every  three 
or  four  hours. 

The  measure  can  only  claim  to  be  palliative,  and  to  place 
the  patient  in  a  more  favourable  condition  for  operation. 
Kussmaul,  however,  claims  that  it  may  lead  to  the  complete 
cure  of  the  patient.  He  gives  two  cases  in  illustration  of 
this  which  are  certainly  hard  to  interpret.  In  one  instance 
there  was  complete  obstruction  for  eight  days  with  "fseculent  " 
vomiting.  The  patient  made  a  good  recovery  after  the 
stomach  had  been  washed  out  five  times  in  twelve  hours. 

In  another  example  the  obstruction  had  lasted  for  nine 
days,  and  recovery  followed  upon  one  washing  out  of  the 
stomach.  My  experience  of  the  measiu^e  is  such  that  I 
f-hould  advise  it  as  a  routine  detail  of  treatment  in  every  ease 
in  which  the  little  operation  can  be  tolerated. 

The  other  measiu'C  which  remains  to  be  considered  is 
puncture  of  the  distended  bowel.  In  this  procedure  an 
aspirator  needle  or  a  fine  trochar  is  thrust  into  the  abdomen 


OTHER    MEASURES    THAN    OPERATION.  471 

over  some  prominent  coil  of  intestine,  and  relief  is  sought  to 
be  afforded  by  the  escape  of  matters,  fluid  and  gaseous,  from 
the  distended  bowel. 

It  cannot  be  said  that  this  is  a  very  scientific  opera- 
tion, nor  one  that  can  be  adopted  with  any  precision  or 
carried  out  with  any  very  definite  purpose. 

It  must,  if  it  be  considered  a  means  of  treatment 
at  all,  be  regarded  as  a  palliative  and  not  as  a  curative 
measure. 

In  some  forms  of  obstruction  gi-eat  distress  is  occasioned  by 
the  distension  of  the  abdomen.  By  such  distension  dyspnoea 
may  be  produced,  the  pain  increased,  and  the  vomiting 
rendered  more  troublesome.  Indeed,  in  some  cases  of  rapid 
and  extreme  distension,  such  as  may  be  met  with  in  volvulus 
of  the  sigmoid  flexure,  the  meteoristic  bowels  may  so  press 
upon  the  diaphragm  and  the  thoracic  viscera  as  to  cause 
more  or  less  sudden  death. 

In  cases  of  great  distension  puncture  usually  affords  very 
considerable  relief.  The  punctures  may  be  repeated  many 
times  or  made  in  many  parts  of  the  abdomen  at  once,  and 
the  amount  of  flatus,  and  occasionally  of  fluid  matter,  that 
may  be  in  this  way  removed  is  often  considerable. 

The  procedure  has  been  recommended  also  as  a  prelimi- 
nary to  laparotomy  by  surgeons  who,  in  performing  this 
operation,  have  been  troubled  by  the  premature  escape  of 
the  distended  coils. 

With  regard  to  puncture  as  a  curative  measure  one  must 
note  that  several  cases  of  obstruction  have  been  recorded 
which  have  been  apparently  cured  by  this  procedure  and  by 
it  alone.  In  illustration,  I  might  take  an  example  of  an 
acute  case  and  then  an  example  of  a  chronic  one  with 
an  acute  ending. 

M.  Le  Fort  mentions  the  case  of  a  man  with  symptoms  of 
acute  internal  strangulation  upon  whom  he  was  about  to 
perform  laparotomy.  Before,  however,  proceeding  to  this 
measure  he  punctured  the  abdomen  with  a  capillary  trochar 
once  in  the  right  hypochondrium  and  twice  in  the  site  of 
the  transverse  colon.  Some  flatus  and  fluid  faeces  escaped. 
The  next  day  the  man  passed  a  copious  motion,  and  a  rapid 
and  complete  recovery  followed.^ 

Mr.  AVorthington  details  a  case  of  chronic  constipation 
ending  in  an  acute  attack  in  the  person  of  a  man  aged  twenty- 
eight..  The  symptoms  were  severe,  there  was  great  meteorism 
and  stercoraceous  vomiting.  On  the  seventh  day  a  fine 
trochar  was  introduced  and  retained  thirty  minutes.     Much 

*  Bull,  et  Mem.  de  la  8oc.  de  Chir.  de  Paris,  1879,  p.  641. 


472  TREATMENT    OF   ACUTE    0 B IS T RUCTION. 

fluid  and  flatus  escaped.  Next  day  a  stool  was  passed,  and 
the  patient  made  a  good  recovery."^ 

Cursclimann  reports  three  cases  of  cure  of  definite 
intestinal  obstruction  after  the  puncturing  of  the  bowel  by  a 
tine  hollow  needle,  the  size  of  a  Pravaz's  syringo. 

Without  discussing  the  probable  nature  of  these  or  of 
Hke  cases  we  may  proceed  to  consider  what  form  or  forms 
of  obstruction  are  likely  to  be  benefited  by  this  mode  of 
treatment. 

Puncture  of  the  involved  coil  has  been  sug-o-ested  as  a 
means  of  cure  in  volvulus  of  the  colon.  It  is  true  that  at 
autopsies  it  has  often  been  found  impossible  to  reduce  a 
volvulus  until  it  had  been  emptied  by  a  trochar,  but  I  am  not 
aware  that  the  emptying  alone  has  been  sufficient  in  any  case 
to  effect  reduction.  Indeed,  I  can  refer  to  cases  both  ol 
volvulus  of  the  sigmoid  flexuref  and  of  the  caecum;^  where 
capillary  puncture  was  resorted  to  during  life  without  any 
enduring  benefit. 

Evacuation  of  the  contents  of  the  upper  segment  of  the 
bowel  may  completely  relieve  obstruction  due  to  kinking,  or  to 
acute  bending  of  the  intestine.  It  may  also  allow  of  the 
spontaneous  reduction  of  a  coil  that  is  lightly  held  under  a 
band  or  is  involved,  without  severe  strangulation,  in  some 
abnormal  aperture.  It  ma}^  afford  marked  and  long- continued 
relief  in  cases  of  temporary  complete  obstruction  depending 
upon  stricture,  upon  any  form  of  stenosis,  upon  f'secal  accumu- 
lation, or  upon  the  impaction  of  a  foreign  substance.  It  may 
give  decided  relief  in  cases  of  chronic  "  stoppage "  where 
symptoms  of  acute  obstruction  have  developed  suddenly  as 
a  result  of  changes  following  upon  great  distension  of 
the  bowel. 

But  even  should  a  correct  diagnosis  be  made  in  such  cases 
as  the  above,  it  must  still  remain  an  open  question  whether 
relief  should  be  sought  by  this  means.  It  is  true  that  in  most 
instances  the  little  operation  is  associated  with  no  evil 
results,  even  if  it  does  not  give  relief,  but  its  application  is 
attended  by  great  uncertainty.  The  proper  coil  of  intestine 
may  be  hit,  or  it  may  not  be.  In  any  case  it  is  probable  that 
the  trochar  would  enter  a  distended  loop,  but  it  may  be  one  so 
far  away  from  the  seat  of  obstruction  that  the  evacuation  of 
its  contents  is  attended  by  no  real  benefit.  In  the  great 
majority   of  cases,   therefore,   the   puncture   must   be  made 

*  Brit.  Med.  Journ.,  vol.  ii.,  1882,  p.  167. 

t  C'ontrib.  a  I'Etude  de  I'Occlus.  intes.    by   J.    M.  Le    Moyne.     These  da 
Paris,  1878. 

:}:  Dr.  Hilton  Fagge  ;  Guy's  Hosp.  Reports,  vol.  xiv.,  p.  272. 


OTHER    MEASUBES    THAN    OPERATION.  473 

purely  at  haztiid  and  blindl}',  and  its  cliances  of  hitting  the 
exact  spot  are  about  those  of  the  arrow  from  the  bow 
"  drawn  at  a  venture."  In  not  a  few  instances  the  trochar 
has  entered  the  bowel  below  the  obstruction. 

It  must  further  be  pointed  out  that  puncture  of  the 
intestine  is  not  quite  so  entirely  harmless  a  procedure  as  is 
sometimes  supposed.  The  punctured  gut  is  much  distended 
and  often  in  a  state  of  temporary  paralysis  ;  so  that  after  the 
trochar  is  withdrawn  the  little  hole  is  not  etficiently  closed, 
and  ftecal  extravasation  may  follow.  The  more  minute  the 
trochar  the  smaller  the  hole  to  be  closed,  but  at  the  same  time 
the  amount  of  matter  evacuated  by  very  slight  instruments 
is  so  trifling  that  the  operation  has  no  raison  d'etre.  Then, 
again,  the  puncture  may  involve  a  friable  piece  of  gut  on.,  the 
point  of  gangrene,  and  ftecal  extravasation  may  again  ensue. 
Mr.  Hulke,  in  performing  a  laparotomy,  punctured  the 
distended  intestine.  The  gut  so  treated  was  in  a  precari- 
ous condition.  The  hole  did  not  close,  attempts  to  close  it 
made  it  larger,  until  at  last  it  had  to  be  converted  into  an 
artificial  anus.* 

In  more  than  one  instance  the  patient  has  been  saved 
from  peritonitis,  but  a  ftecal  fistula  has  formed  at  the  seat 
of  puncture. 

The  conclusion  one  must  come  to  is  this,  that  puncturing 
of  the  distended  bowel  in  acute  intestinal  obstruction  is  not  a 
rational  method  of  treatment  and  is  not  justified  as  a  measure 
of  common  practice  by  the  few  instances  in  which  it  has  been 
reported  to  have  led  to  a  good  result. 

If  it  be  deemed  desirable  to  puncture  the  bowel,  the 
abdomen  should  be  opened  and  the  puncture  made  definitely 
and  precisely.  The  opening  need  but  be  small,  provided  it  is 
decided  that  nothing  more  is  to  be  done.  In  short,  if  the 
bowel  is  to  be  tapped  let  the  operation  be  done  on  sound 
surgical  principles.  In  pre-antiseptic  days  there  was  some 
excuse  for  a  halting,  timid,  and  speculative  measure  like  that 
now  under  notice ;  at  the  present  day  there  is  no  excuse.  If 
I  were  called  upon  to  tap  a  distended  intestine  I  would  prefer 
first  of  all  to  see  the  particular  coil  which  I  intend  to  puncture, 
a,nd  I  should  consider  such  a  procedure  less  dangerous  than  the 
blind  plunging  of  a  trochar  into  the  midst  of  a  collection  of 
distended  loops  of  gut.  It  may  be  said  that  the  trochar  can 
be  used  without  an  ansesthetic  and  that  an  incision  cannot. 
To  this'  it  must  be  replied  that  with  the  use  of  eucaine  the 
small  cut  needed   to   perform  the   operation  with   precision 

*  Medical  Times  and  Gazette,  vol.  ii.,  1872,  p.  482.  See  also  Paper  by  Prof. 
G.  MacLeod;  Glasgow  Med.  Joitru.,  March,  I8S4,  p.  167. 


474  TREATMENT    OF    ACUTE    OBSTRUCTION. 

involves  no  more  pain  than  it  would  be  humane  to  call  upon 
the  patient  to  endure.  The  cases  concerned,  it  must  be 
remembered,  are  for  the  most  part  desperate  cases. 

I  think  that  puncturing  ot  the  bowel  with  a  trochar 
through  an  intact  abdominal  wall  is  only  justified  in  in- 
stances in  which  any  major  operation  is  absolutely  declined 
by  the  patient. 


475 


CHAPTER   II. 

THE    OPERATIVE    TREATMENT    OF    ACUTE    INTESTINAL 
OBSTRUCTION. 

1.  The  Necessity  for  Operation. — There  is  one  measure 
for  the  treatment  of"  acute  intestinal  obstruction,  and  that  is 
by  means  of  laparotomy.  The  operation  should  be  performed 
at  the  earliest  possible  moment ^ — as  soon,  indeed,  as  the 
diagnosis  is  reasonably  clear.  In  cases  of  acute  abdominal 
trouble  in  which  the  diagnosis  is  not  clear  the  better  and 
safer  course  is  to  operate.  I  am  assuming  that  the  symptoms 
in  these  doubtful  instances  are  showing  no  improvement,  and 
that  there  is  at  least  a  reasonable  suspicion  that  the  cause  of 
the  trouble  is  intestinal  obstruction. 

The  worst  feature  of  all  in  the  management  of  a 
case  of  acute  intestinal  obstruction  is  delay.  The  operation 
may  be  dangerous,  and  is,  indeed,  very  dangerous,  but  delay 
is  worse.  The  one  perpetually  reiterated  comment  upon  the 
fatal  cases  of  laparotomy  performed  for  acute  obstruction  is 
this — "  the  operation  was  performed  too  late."  There  can  be 
no  purpose  in  delay,  the  expectant  treatment  has  had  a  very 
extended  and  very  deadly  trial  in  the  past,  and  the  age  for 
miracles  is  past.  There  is  no  avoiding  the  fact  that  acute 
intestinal  obstruction  if  unrelieved  ends  in  death.  It  is 
perfectly  true  that  there  are  isolated  instances  of  spontaneous 
recovery  in  cases  of  acute  obstruction,  and  that  among 
examples  of  acute  intussusception  the  number  of  cases  of 
spontaneous  cure  is  not  in  the  aggregate  small.  Some  very 
faint  reason  for  delaying  operative  interference  may  be  pleaded 
in  the  case  of  acute  intussusception  because  there  is  no  deny- 
ing that  patients  have  recovered  from  that  affection  without 
operation.  But  when  the  whole  mass  of  the  cases  is  considered 
the  number  of  those  examples  of  recovery  is  so  miserably  few 
that  they  form  no  kind  of  ground  for  depriving  the  patient  ol 
a  hope  of  life  by  operation. 


476  TREATMENT    OE   ACUTE    OBSTRUCTION. 

There  can  be  no  shadow  of  doubt  that  the  risk  of  the 
operation  in  intussusception  is  infinitely  less  than  the  risk  of 
leaving  the  case  alone.  I  have  known  a  patient  recover 
spontaneously  without  any  operation  from  strangulated  hernia 
and  from  the  fsecal  fistula  which  resulted,  but  that  fact  would 
be  no  argument  for  delaying  the  operation  of  herniotomy 
in  the  face  of  the  knowledge  that  the  overwhelming 
majority  of  the  subjects  of  strangulated  hernia  die  if  left 
untreated.  There  is  at  least  one  instance  in  which  a  person 
has  jumped  from  the  Suspension  Bridge  at  Clifton  and 
escaped  with  life  and  a  few  minor  injuries,  but  this  would 
not  justify  a  feeling  of  hopefulness  m  others  who  might 
wish  to  perform  the  feat  and  return  alive  to  their  homes. 

In  forms  of  acute  intestinal  obstruction  other  than  acute 
intussusception  the  prospect  of  spontaneous  recovery  is  so 
utterly  insignificant  that  it  must  absolutely  be  disregarded  by 
those  responsible  for  advising  the  patient.  Those  who  arc 
enamoured  of  statistics  could,  I  have  little  doubt,  show  that  it 
is  less  dangerous  to  leap  from  the  Clifton  Suspension  Bridge 
than  to  suffer  from  acute  intestinal  obstruction  and  decline 
operation. 

The  circumstances  of  a  case  of  acute  obstruction  are 
circumstances  of  almost  tragic  gravity.  A  young  man  in 
robust  health  is  seized  with  symptoms  of  strangulation  in 
the  early  morning,  and  before  the  night  has  come  an  operation 
is  advised,  which  is  acknowledged  to  be  attended  with  an 
enormous  risk  to  life. 

It  is  little  to  be  wondered  at  that  the  surgeon  may  waver 
when  pressed  as  to  the  certainty  of  his  conviction  that  there 
is  a  strangulation  of  a  loop  of  bowel.  It  is  impossible  not  to 
be  influenced  a  little  by  the  arguments  of  the  patient's  friends 
to  the  effect  that  so  few  hours  have  passed  since  the  attack 
began,  that  no  time  has  been  allowed  for  the  "  case  to  be 
watched,"  that  no  remedial  measures  of  any  kind,  except 
morphia  and  starvation,  have  been  resorted  to  or  tried.  The 
awkward  questions  come  up  "  Has  there  never  been  a  case 
known  in  which  a  patient  has  recovered  without  operation  ? " 
and  "  How  many  of  those  who  submit  to  the  operation  escape 
with  their  lives  ? "  In  the  midst  of  this  terrible  crisis  and 
this  desperate  conflict  of  hopes  and  fears  there  is  sure  to 
arise  the  evil  whisper,  "Why  not  wait  until  to-morrow  and 
see  how  the  patient  is  then?"  and  so  that  delay  which, 
as  a  rule,  means  death,  is  tacitly  sanctioned,  and  the  case 
enters  into  a  direr  pass. 

The  position  of  the  surgeon  in  these  distressing  cases 
should,  I  think,  be  this.     After  he  has  given  the  matter  the 


THE    NECESSITY    FOR    OPER'ATIO-N.  ill 

fullest  consideration  and  has  concluded  that  an  operation 
must  be  performed,  lie  should  advise  that  course,  should  point 
out  precisely  what  are  the  risks  involved,  and  should  leave 
the  entire  responsibility  of  modifying  that  advice  with  those 
who  are  in  a  position  to  accept  such  responsibility. 

It  must  be  remembered  that  the  average  duration  of  life 
in  intestinal  obstruction  of  a  deiinitely  acute  type  is  only 
about  six  days.  The  success  of  the  operation  depends  com- 
paratively little  upon  the  precise  species  of  obstruction  and 
still  less  upon  the  modus  operandi,  the  age  of  the  patient, 
and  the  previous  treatment  or  neglect  of  treatment.  It 
depends  upon  the  position  of  the  gut,  and  that  condition 
is  influenced  above  all  things  by  the  lapse  of  time.  The 
degree  of  degeneration  in  the  gut  is  most  fitly  to  be 
measured  by  the  number  of  hours  which  have  elapsed  since 
the  attack  began. 

Operation  in  these  cases  is  too  often  regarded  as  a  last 
resource.  It  should  be  regarded  as  the  Ji7'st  resource,  as 
it  certainly  is  the  only  resource. 

It  must  not  for  one  moment  be  supposed  that  the  opera- 
tion for  acute  intestinal  obstruction  is  a  trifling  one.  It 
cannot  be  spoken  of  as  "  little  more  than  an  exploratory 
incision."  The  ordinary  exploratory  incision,  carried  out,  for 
example,  in  the  case  of  a  doubtful  tumour  of  long  standing, 
is  attended  with  but  a  trifling  risk,  and  probably  at  the 
present  day  does  not  involve  a  mortality  of  more  than  1  per 
cent.  It  would  be  utterly  wrong  and  utterly  misleading  to 
compare  such  an  exploratory  incision  with  the  simplest  in- 
cision made  in  acute  intestinal  obstruction.  It  may  be  that  in 
the  latter  case  the  wound  is  only  one  inch  and  a  half  in 
length,  and  that  immediately  the  abdomen  is  opened  a  con- 
strictino'  band  is  found  and  divided,  and  that  the  incision  is  at 
once  closed  without  the  least  disturbance  of  parts.  So  far  as 
the  actual  operation  and  the  actual  cutting  are  concerned, 
such  a  measure  cannot  be  said  to  be  more  grave  than  is 
the  ordinary  exploratory  incision,  but  so  far  as  risks  are 
concerned  it  is  perhaps  thirty  or  even  fifty  times  more 
serious.  In  the  case  of  acute  intestinal  obstruction  the 
surgeon  is  dealing  with  distended  bowels  which  are  filled 
with  septic  matter,  and  very  little  disturbance  of  the  wall 
of  the  gut  is  required  to  allow  that  septic  material  to  reach 
the  peritoneum,  and  to  cause  death  from  peritonitis  and 
septicemia.  I  have  had  just  such  a  case  as  has  been  now 
described.  The  operation  was  done  early  and  under  favour- 
able conditions ;  a  thin  band  was  at  once  revealed  and 
divided,  and  the  abdominal  wound  was  closed.    The  operation 


478  TREATMENT    OF   ACUTE    OBSTRUCTION. 

did  not  occupy  more  than  fifteen  minutes,  and  yet  the  patient 
died  of  a  low  type  of  septicpemia,  in  which,  no  doubt,  the 
poison  had  reached  the  system  through  the  peritoneum. 

2.  The  Anaesthetic. — In  all  operations  for  acute  intestinal 
obstruction  a  special  degree  of  danger  attends  the  adminis- 
tration of  any  anaesthetic,  and  it  may  be  at  once  said 
that  the  less  anaesthetic  administered  and  the  shorter  the 
duration  of  anaesthesia  the  better.  Danger  especially  attends 
those  cases  in  which  operation  has  been  unduly  delayed,  in 
which  there  is  considerable  distension  of  the  abdomen,  in 
which  the  stomach  is  full  of  foul  matter  that  has  ascended 
from  the  intestine,  and  in  which  much  morphia  has  been 
given.  In  such  instances  it  is  unfortunately  no  rare  experience 
to  find  that  as  soon  as  the  reflexes  are  abolished  by  the 
anaesthetic  there  is  a  gush  of  vomit  from  the  mouth  and 
nostrils,  and  the  patient  is  dead.  Several  of  such  cases 
have  come  under  my  own  notice. 

Another  danger  met  with  in  the  same  class  of  patient 
depends  upon  the  inhalation  of  vomit  into  the  lung.  This 
accident  may  lead  to  almost  immediate  death,  and  if  the 
patient  leave  the  operating  table  alive  may  be  followed  by 
a  fatal  septic  pneumonia.  Incidentally  I  may  here  mention 
that  not  a  few  of  these  operation  cases  die  of  such  a  pneu- 
monia. I  do  not  think  that  the  lung  trouble  is  always  due 
to  the  inhalation  of  vomited  matter,  as  in  many  instances  it 
appears  rather  to  be  the  outcome  of  a  general  septicaemia. 

The  dansrers  attending-  the  anaesthetic,  to  which  allusion 
has  been  made,  may  be,  to  a  great  extent,  met  by  washing 
out  the  stomach  before  the  patient  is  placed  upon  the  table. 
I  am  so  impressed  with  the  value  of  this  measure  that  I 
think  it  should  be  adopted,  whenever  possible,  as  a  routine 
preliminary  to  operation.  It  is  also  to  be  recommended 
that  some  little  time  before  the  operation  an  enema  con- 
taining brandy  should  be  administered  by  the  rectum,  and 
also  tnat  a  hypodermic  injection  of  strychnia  (to  the  amount 
of  ^Vth  of  a  grain  for  an  adult)  should  be  given  before  the 
operation  is  commenced.  The  value  of  strychnia  in  these 
circumstances  is,  I  think,  undoubted. 

As  to  the  choice  of  the  anaesthetic  employed  I  would 
prefer  to  leave  that  to  the  administrator.  The  comparative 
value  of  anaesthetics  depends  largely  upon  the  comparative 
experience  of  the  administrator  in  one  or  other  of  the  drugs 
employed.  That  anaesthetist  will,  as  a  rule,  do  best  who 
gives,  not  the  drug  ordered,  but  the  drug  with  the  use  of 
which  he  is  most  familiar.  Should  no  such  choice  be  ex- 
pressed it  has  appeared  to  me  that  ether  or  gas  and  ether 


TEE    OPERATION.  479 

have  distinct  advantages  as  to  efficacy  and  safety  over 
cliloroform.  It  is  impossible  and  unreasonable  to  insist  upon 
absolute  relaxation  or  even  upon  absolute  immobility  of  the 
patient  in  these  anxious  and  urgent  cases.  The  subjects  ot 
these  operations  are  often  so  exhausted  and  so  stupefied  by 
morphia  that  but  a  very  trifling  degree  of  anaesthesia,  hardly 
amounting  even  to  mental  insensibility,  is  required. 

In  some  extreme  cases  in  which  the  distension  is  con- 
siderable and  the  patient  very  feeble,  or  in  which  operation 
has  been  long  postponed,  it  may  appear  dangerous  to  give 
an  anaesthetic  of  any  kind.  In  such  desperate  examples  I 
have  performed  both  enterostomy  and  even  a  fully  completed 
inguinal  colotomy  without  any  anaesthetic  beyond  the  local 
application  of  cocaine  or  eucaine.  When  once  the  skin 
incision  is  made  singularly  little  pain  is  complained  of  by 
these  almost  moribund  patients.  I  need  not  say  that  in  such 
cases  nothing  is  attempted  beyond  the  opening  and  evacua- 
tion of  the  first  fully  distended  coil  which  presents.  The 
surgeon's  aim  is  merely  an  attempt  to  save  a  fast-ebbing 
life  by  relieving  that  which  is  causing  death,  namely,  an  over- 
loaded bowel  with  septic  contents. 

3.  The  General  Details  of  the  Operation. — Before  the 
operation  the  whole  of  the  skin  of  the  abdomen  should  be 
prepared  as  in  the  most  precise  aseptic  operations. 

These  preparations  are  often  of  necessity  imperfect,  owing 
to  the  urgency  of  the  case  and  the  inability  of  the  patient  to 
submit  to  the  tedious  and  probably  not  painless  scrubbing  and 
cleansing  of  the  skin  which  are  essential.  These  preliminaries 
to  the  operation  have  had  to  be  abandoned  on  account  of  the 
amount  of  pain  and  the  increased  vomiting  produced.  They 
should,  however,  be  carried  out  with  the  fullest  detail  when- 
ever possible,  as  during  the  operation  numerous  coils  of  bowel 
may  be  lying  upon  the  surface  of  the  abdomen.  The  skin  in 
these  cases  has  often  been  reduced  to  a  very  undesirable  con- 
dition of  uncleanness  by  the  use  of  linseed-meal  poultices  and 
the  liberal  inunction  of  belladonna.  It  is  no  kindness  to  the 
patient  to  relax  these  essential  preparations  on  the  ground 
that  they  cause  temporary  inconvenience.  If  owing  to  the 
neglect  of  such  preparations  the  peritoneum  is  going  to  be 
infected  during  the  operation,  this  procedure  may  as  well  not 
be  performed.  The  final  cleansing  of  the  surface  may  be 
carried  out  while  the  patient  is  being  anaesthetised,  but  it 
must  be  remembered  how  precious  is  every  moment  in  these 
cases  when  once  the  patient  is  on  the  table.  The  pubic  hair 
should  be  shaved  and  the  bladder  emptied  by  catheter. 

In  one  reported  case,  in  a  male  patient,  the  bladder  was 


480  TEEATMEyT    OF   ACUTE    OBSTRTJGTION. 

cut  into  during  the  preliminary  incision  and  urine  escaped 
into  the  peritoneal  cavity.     The  patient  died."^ 

Care  should  be  taken  that  the  patient  is  kept  very  warm 
during  the  operation. 

The  Incision. — The  incision  should  be  made  in  the  median 
Ime  between  the  umbilicus  and  pubes.  Through  an  incision  so 
placed  the  most  efficient  examination  of  the  abdomen  can  be 
made  and  the  conditions  most  commonl}^  met  with  be  most 
readily  dealt  with.  The  median  incision  can  be  enlarged  to  a 
greater  extent  and  with  less  disturbance  of  parts  than  can  a 
lateral  one.  The  simplest  cut  for  the  opening  of  the  abdomen 
is  undoubtedly  through  the  median  line,  and  the  closure  of 
such  incision  can  be  effected  with  the  least  expenditure  of 
time  and  trouble.  If  an  artificial  anus  or  ftecal  fistula  has  to  be 
established,  it  Avill  probably  only  be  a  temporary  one  and  it  is 
by  no  means  inconveniently  placed  if  located  in  the  middle  line. 

Experience  is  decidedly  against  the  making  of  the  incision 
over  the  supposed  seat  of  the  obstruction.  Such  a  procedure 
assumes  a  very  accurate  diagnosis,  and  in  dealing  with  cases 
of  acute  obstruction  such  precise  diagnoses  are  not  to  be 
depended  upon.  Thus,  swellings  have  been  cut  down  upon 
which  have  had  no  connection  with  the  intestinal  trouble. 
An  incision  has  been  made  in  the  left  semi-lunar  line,  and  the 
site  of  the  obstruction  has  been  found  to  be  in  the  right  iliac 
fossa.  In  one  case  of  laparotomy  for  intussusception  the 
operation  had  to  be  practically  abandoned  because  the  incision 
had  been  made  in  a  lateral  segment  of  the  abdomen,  and 
the  surgeon's  manipulations  were  in  consequence  seriously 
restricted,  t 

There  is  no  variety  of  intussusception  which  has  not  at 
one  time  or  another  been  reduced  through  an  incision  in 
the  median  line. 

Even  in  cases  where  the  obstruction  is  supposed  to  depend 
upon  some  morbid  condition  in  the  loop  of  gut  reduced  from 
an  external  hernia,  it  is  better  as  a  rule  to  make  the  cut  in  the 
middle  line  over  the  seat  of  the  hernia.  A  cut  in  the  abdomen 
through  the  region  of  the  inguinal  canal  greatly  limits  the 
surgeon's  sphere  of  action  and  maj'  render  the  operaiion  use- 
less should  an  error  have  been  made  in  the  diagnosis. 

Thus,  in  cases  supposed  to  depend  upon  an  external  hernia 
an  incision  has  been  made  over  the  sac ;  nothing  has  been 
found  of  note  ;  the  wound  has  been  closed,  and  a  second  cut 
made  in  the  linea  alba,  j 

*  Dr.  Atherton;  Boston  Med.  and  Surg.  Jotirn.,  1883,  p.  531. 

t  Lancet,  vol.ii.,  1S82,  p.  1036. 

+  Ibid.,  vol.  i.,  1878,  p.  493  ;  Mr.  Bradley's  case. 


THE    OPE  RATION    IN    EXTREME    OASES.  481 

A  median  incision  made  below  the  umbilicus  may,  of 
course,  prove  to  be  wrongly  placed,  as,  for  example,  when 
such  an  incision  is  made  in  a  case  of  hernia  into  the  foramen 
of  Winslow.  There  is  no  reason,  however,  in  this  cr  any 
parallel  case  against  a  second  incision  being  made  into  the 
abdomen  at  a  more  convenient  spot.  I  have  several  times 
made  two  such  wounds — -through  one  the  diagnosis  of  the 
site  of  the  trouble  was  made,  and  through  the  other  the 
trouble  Avas  treated. 

These  exceptional  cases  afford  no  argument  against  the 
rule  that  the  incision  is  best  placed  in  the  median  line  below 
the  umbilicus. 

In  cases  attended  with  great  distension  of  the  bowel  the 
peritoneum  must  be  divided  Avith  the  utmost  care,  as  the 
bowel  is  very  easily  wounded.  I  have  known  an  instance  in 
which  the  wall  of  a  greatly  attenuated  coil  of  ileum,  filled  with 
iiatus,  was  mistaken  ibr  the  peritoneum  and  opened.  The 
serous  membrane  had  been  already  divided,  and  as  no  cavity 
was  made  apparent  the  gut  was  mistaken  for  the  peritoneum 
bulging  into  the  wound. 

The  incision  should  at  first  be  made  large  enough  to  admit 
two  fingers.  These  two  fingers  are  cautiously  introduced.  In 
some  few  fortunate  cases  the  diagnosis  may  be  made  at  once  ; 
a  band  may  be  detected  about  the  right  iliac  fossa  or  a 
Meckel's  process  may  be  discovered  passing  from  the  umbilicus, 
or  the  case  be  made  evident  to  be  one  of  volvulus  of  the 
sigmoid  flexure.  When  the  symptoms  of  acute  intussuscep- 
tion are  present  the  invagination  tumour  may  at  once  be 
detected  by  the  exploring  fingers. 

Such  cases  are — as  has  just  been  said — fortunate.  They 
are  also  very  rare. 

The  Operation  in  Extreme  Cases. — In  the  most  extreme 
type  of  case  it  is  possible  that  the  exploration  may  not  be 
safely  extended  beyond  what  is  discoverable  by  two  fingers 
very  gently  introduced  and  very  gently  passed  through  as 
wide  an  area  as  the  distension  of  the  abdomen  will  permit.  If 
the  cause  of  the  obstruction  be  happily  discovered  in  this  very 
casual  examination,  it  may  there  and  then  be  dealt  with, 
and  in  any  case,  whether  the  cause  be  found  or  not,  the  most 
distended  of  the  coils  which  present  is  opened  by  the  operation 
of  enterostomy  (page  488).  This  represents  all  that  is  done  in 
the  most  extreme  cases.  The  patient  will  stand  but  little,  and 
an  enterostomy  carried  out  after  the  most  superficial  examin- 
ation represents  the  maximum.  It  is  a  well-known  fact  that 
these  operations  in  which  a  small  incision  has  been  made,  and 
in  which,  without  further  inquiry,  or  after  the  most  trivial 

F  F 


482  TREATMENT    OF    ACUTE    OBSTRUCTION. 

examination,  the  first  presenting  coil  has  been  secured  a,nd 
opened,  have  been  attended  with  apparently  excellent  results. 
The  connxient  upon  that  fact  is  twofold  :  firstly,  that  the 
evacuation  of  the  distended  bowel  is  a  very  essential  thing ; 
and,  secondly,  that  the  less  the  interior  of  the  abdomen  is 
disturbed  the  better. 

When  the  first  edition  of  this  book  Avas  published  the  best 
results  as  regards  mortality  after  laparotomy  for  acute 
intestinal  obstruction  attended  those  cases  in  which  an 
enterostomy  had  been  performed  with  or  without  previous 
searching  for  the  cause  of  the  trouble. 

In  most  of  these  cases  the  small  intestine  had  been 
opened  ;    in  some  few  the  colon. 

It  is  a  fact,  and  it  is  a  very  fortunate  one,  that  the  most 
distended  coil,  whether  it  belongs  to  the  large  or  the  small 
intestine,  tends  to  make  its  way  to  the  front,  and  thus  it 
happens  that  the  coil  which  presents,  or  which  a  slight  ex- 
amination brings  to  the  front,  is  very  often  indeed  the  most 
dilated  coil,  and  the  one  most  in  need  of  opening. 

This  operation  for  the  extreme  type  of  case  is  very  slight, 
occupies  but  a  few  minutes,  and  may  be  performed,  under 
pressing  circumstances,  without  an  anassthetic  (page  479). 

Against  this  very  rough-and-ready  operation  a  vast  array 
of  arguments  may  be  advanced. 

In  a  simple  enterostomy  the  cause  of  the  obstruction  is 
left  untouched.  There  may  be  within  the  abdomen  a  volvulus 
of  bowel,  which  is  on  the  point  of  gangrene,  or  a  coil  ot 
strangulated  intestine  which  is  left  unrelieved,  and  which  will 
certainly  become  gangrenous  in  due  course,  or  there  may  be 
an  unreduced  intussusception  which  will  in  time  attain  the 
same  undesirable  end. 

In  the  case  of  the  intussusception  a  spontaneous  cure  iiiay 
follow,  but  in  the  other  forms  of  strangulation  there  is  little 
to  be  said  beyond  this :  that  if  such  conditions  as  are  just 
described  be  present  the  cases  are  hopeless,  and  can,  so  far  as 
we  know,  only  end  in  death. 

Such  arguments  are  to  be  answered  by  the  knowledge 
that  the  condition  of  the  patient  is  such  that  he  could  not 
survive  a  protracted  operation,  involving  a  long  search  for  the 
strangulated  loop,  and  including  measures  for  its  relief  and 
for  the  final  formation  of  a  faical  fistula. 

Such  a  complete  measure  is  no  doubt  desirable  in  the 
abstract,  but  in  the  extreme  cases  with  which  we  are  now 
dealing  it  is  absolutely  impossible. 

Above  all  arguments  remains  the  fact  that  this  un- 
doubtedly  uncouth   measure  has  been  the  means  of  saving 


THE    OPERATION    IX    EXTL'EME    CASES.  183 

life.  Unfortunately,  we  know  v^eiy  little  of  the  condition  of 
the  intestine  in  those  cases  Avhich  have  made  a  complete 
recovery  after  a  hurriedly  performed  enterostomy.  From  an 
examination  of  certain  of  the  cases  I  am  convinced  that  not  a 
few  (and  possibly  the  majority)  have  been  the  subject-s  of 
erroneous  diagnosis. 

In  some  there  has  been  peritonitis,  due  probably  to 
mischief  in  the  vermiform  appendix,  and  no  acute  intestinal 
obstruction  has  existed  at  all.  It  is  easy  to  understand  that 
in  such  examples  a  good  recovery  may  follow  the  opening  of 
the  belly  and  the  evacuation  of  the  gut.  I  am  afraid  that  a 
good  number  of  the  cases  of  "  cure "  of  acute  intestinal 
obstruction  by  simple  enterostomy  come  under  this  category, 
and  are  really  cases  of  peritonitis. 

A  series  of  cases  in  which  laparotomy  was  performed  for 
acute  obstruction,  and  in  which  there  was  no  obstruction 
found,  but  only  the  manifestations  of  peritonitis,  has  been 
collected  by  Duplay."^  Another  marked  case  of  this  type  is 
placed  on  record  by  Dr.  Buchanan  of  Glasgow  : 

A  woman  of  twenty-nine  years  of  age  was  suddenly  seized  with  severe 
abdominal  pain,  soon  followed  by  vomiting.  The  attack  came  on 
on  Feb.  18th,  at  2  a.m.,  after  eating  a  hearty  supper.  The  pain  and 
vomiting  became  more  severe,  and  at  4  a.m.  on  Feb.  20th  the  ejected, 
matters  were  stercoraceous.  There  was  absolute  constipation,  and 
enemata  gave  no  relief.  On  Feb.  21st  the  patient  was  greatly  pros- 
trated, the  eyes  were  sunken,  the  voice  husky,  the  limbs  cold.  The 
case  was  considered  to  be  one  of  obstruction.  Median  laparotomy  was 
performed  (non-antiseptic).  One  pint  of  turbid  serum  containing 
curd-like  flocculi  escaped.  There  were  extensive  recent  adhesions 
involving  all  the  intestines.  No  obstruction  was  found.  The  pelvis 
was  sponged  out  and  the  wound  closed.  The  patient  made  an  excellent 
recovery. t 

In  this  instance  it  is  very  probable  that  the  trouble 
started  in  a  diseased  vermiform  appendix. 

In  some  of  the  examples  of  enterostomy  the  case  was 
possibly  not  so  urgent  as  appeared  at  the  time.  I  am  aware 
of  a  case  in  which  an  adult,  said  to  have  been  free  from  gross 
abdominal  symptoms,  was  seized  with  acute  intestmal  obstruc- 
tion. In  a  few  days  he  was  believed  to  be  in  extremis.  A 
hurried  enterostomy  was  performed  without  preliminary  ex- 
amination, and  a  coil  of  ileum  was  opened.  The  patient  died 
of  marasmus,  and  the  post-mortem  revealed  a  quite  un- 
suspected stricture  at  the  termination  of  the  sigmoid  flexure. 
The  acute  attack  had  been  due  to  the  sudden  blocking  of  the 
stricture,  or  more  probably  to  the  kinking  of  the  bowel  at  the 

*  An-hivcs  Gen.  de  Med.,  1876,  p.  513. 
f  Lancet,  vol.  i.,  1871,  p.  776. 


484  TREATMENT    OF   ACUTE    OBSTRUCTION. 

narrowed  part.  Such  a  case  as  this  is  not  an  encouraging 
comment  upon  the  operation  now  under  consideration. 

However,  as  surgery  advances  there  is  no  doubt  but  that 
this  extreme,  irrational  and  blindly-devised  operation  will 
become  less  and  less  frequent,  partly  because  operation  in 
cases  of  acute  obstruction  will  not  be  delayed  so  long  that 
the  patient  can  merely  undergo  this  minimum  measure,  and 
partly  because  more  precise  information  will  increase  the 
doubt  as  to  the  efficacy  of  this  procedure  in  genuine 
examples  of  acute  intestinal  obstruction. 

All  that  can  be  said  at  present  is  that  such  evidence  as 
we  possess  is  in  favour  ot  the  operation  in  extreme  cases  in 
Avhich  the  patient  can  only  be  submitted  to  a  procedure  of 
the  slightest  magnitude. 

The  Search  for  the  Obstruction. — To  return  to  the  per- 
formance of  the  operation  in  what  may  be  considered  to  be  the 
average  case.  A  small  incision  has  been  made  in  the  median 
line  and  a  superficial  examination  of  the  parts  beneath  has 
been  very  gently  made  by  two  fingers  introduced  through 
such  incision  (page  480).  Such  examination  has  not  revealed 
the  cause  of  the  obstruction  and  the  patient's  condition 
warrants  a  further  search  after  that  cause.  The  median  in- 
cision is  freely  enlarged  and — if  the  distension  be  not  con- 
siderable— the  four  fingers  are  introduced  gently  into  the 
abdomen  and  carried  into  the  right  iliac  fossa.  The  csecum 
is  felt  for  or  possibly  exposed,  and  if  it  be  found  to  be  much 
distended  the  obstruction  is  probably  in  the  colon ;  if  it  be 
found  to  be  empty  and  flaccid  the  strangulation  may  be 
assumed  to  concern  the  small  intestine.  A  band  or  a 
Meckel's  diverticulum,  or  a  hernia  through  a  slit  in  the 
mesentery  or  an  intussusception  may  be  discovered,  as  the 
right  iliac  fossa  is  a  common  site  of  the  trouble  in  acute 
obstruction.  Failing  any  such  discovery,  the  fingers  are 
passed  into  the  pelvis,  where  possibly  bands  or  adherent 
organs  may  be  met  with,  or  collapsed  coils  of  small  intestine 
below  the  obstruction  discovered.  Such  coils,  if  drawn  for- 
wards, may  lead  to  the  seat  of  trouble.  If  the  examination  so 
far  be  negative,  the  fingers  are  passed  on  to  the  left  iliac 
fossa,  which  is  in  like  manner  examined,  with  the  proviso 
that  no  force  is  employed.  During  the  process  of  this 
investigation  the  hernial  orifices  are  examined,  especially 
the  obturator  canal.  In  this  inquiry  there  must  be  no  rough 
manipulation  of  the  distended  bowels  and  the  fingers  should 
keep  throughout  between  the  intestines  and  the  parietes, 
so  far  as  is  possible.  The  whole  hand  should  not  be  mtro- 
duced.       Assuming    that   in    spite    of   this   examination  no 


THE    SEARCH   FOR    THE    OBSTRUCTION.  4S5 

case  of  obstruction  be  found,  the  surgeon  is  brought  face  to 
face  with  the  most  difficult  and  the  most  dangerous  features 
of  the  operation. 

Further  examination  is  hindered  by  reason  of  the  dis- 
tended coils  of  intestine,  and  such  is  the  state  of  these 
intestines  that  they  have  to  be  handled  with  the  very  utmost 
care.  Indeed,  in  some  cases  it  seems  almost  impossible  to 
touch  them.  The  serous  coat  of  the  dilated  coils  is  very 
much  on  the  stretch  and  tears  on  the  least  traction.  It  is 
rent  by  a  mere  touch  of  a  rough  finger-nail. 

In  drawing  a  dilated  coil  forwards  through  a  too  small 
incision  I  have  seen  three  or  four  rents  develop  in  the  serous 
coat.  These  rents  mean  three  or  four  channels  through 
which  the  peritoneum  may  be  infected  by  the  septic  matter 
within  the  bowel.  The  distension  of  the  bowel  is  mostly  due 
to  flatus,  and  two  courses  are  now  suggested  :  one  is  to 
puncture  the  dilated  coils,  and  so  remove  the  distension ;  and 
the  other  is  to  enlarge  the  incision  without  reservation  and 
allow  the  mass  of  distended  intestines  to  protrude.  In  the 
early  days  of  intestinal  surgery  there  was  a  great  outcry 
against  the  allowing  of  the  intestines  to  protrude  and  nmch 
prejudice  in  favour  of  the  smallest  possible  incision.  Under 
the  influence  of  these  prejudices  the  wdiole  hand  was  forced 
into  the  distended  abdomen  and  the  forearm  introduced  often 
half  way  to  the  elbow.  There  was  then  made  a  blind  ex- 
ploration of  the  abdomen,  the  ever-moving  fingers  being 
forced  in  and  out  among  distended  coils  which  were  on  the 
verge  of  bursting.  It  was  soon  made  evident  that  this 
examination  possibly  involved  a  hundred  rents  in  the  peri- 
toneum and  reduced  the  patient's  chance  of  life  to  a  vanishing 
point.  It  will  now  be  accepted  as  a  fact  that  the  allowing  of 
the  whole  mass  of  the  intestines  to  gush  forth  is — if  suitable 
precautions  be  observed— hot  so  grave  a  matter  as  the 
examination  of  the  abdominal  cavity  by  means  of  the  whole 
hand  introduced  through  an  incision  only  just  large  enough 
to  admit  it. 

To  return  to  the  two  possible  courses  of  treatment  which 
have  just  been  mentioned  and  to  consider,  first,  the  question  of 
puncture  of  the  bowel.  If  the  whole  distension  could  be 
relieved  by  one  puncture  this  measure  would  have  no  doubt 
much  to  commend  it ;  but,  unfortunately,  so  far  as  the  small 
intestine  is  concerned,  one  puncture  will  not  relieve  the  dis- 
tension, and  probably  even  twenty  punctures  will  not  effect 
that  end.  The  puncture  will  relieve  the  coil  dealt  with,  and 
possibly  one  or  two  connected  with  it ;  and  that  is  all.  The 
trochar  used  must  be  small,  the  process  of  evacuation  is  very 


486  TREATMENT    OF    ACUTE    OBSTBTJGTION. 

slow,  time  is  precious,  and  each  puncture,  after  it  has  been 
made,  must  be  closed  by  a  suture,  as  it  is^in  these  particular 
cases — very  likely  to  leak.  If,  as  is  probable,  the  surgeon  in- 
tends to  complete  his  operation  by  an  artificial  opening 
(enterostomy),  it  may  be  argued  that  he  should  make  a  free  in- 
cision into  one  coil  of  small  intestine  and  evacuate  the  gut 
through  this  large  aperture.  But  through  such  a  hole  the 
fluid  contents  of  the  gut  will  escape,  and  that  is  not  a  desirable 
circumstance  in  the  middle  of  an  abdominal  operation.  Then, 
again,  even  through  a  large  opening  made  in  the  small 
intestine  the  relief  of  the  distension  is  very  slow  and  often 
very  imperfect,  and,  finally,  when  the  obstruction  has  been 
found,  it  may  be  discovered  that  the  enterostomy  has  been 
made  in  a  very  inconvenient  place,  or  the  revelation  of  a 
gangrenous  knuckle  of  gut  may  demand  a  second  fcBcal 
fistula  to  be  formed. 

It  therefore  happens  that  when  the  distension  involves 
the  lesser  bowel,  search  for  the  cause  of  obstruction  is  not 
likely  to  be  satisfactorily  helped  by  puncturing  the  dilated 
coil  or  coils.  There  rtxay  be  exceptions  to  this  in  cases  in 
which  it  is  apparent  that  the  dilatation  of  the  bowel  is 
limited  in  extent,  and  in  which  a  ready  and  satisfactory 
evacuation  could  be  obtained  through  one  small  puncture 
with  a  fine  trochar.  After  such  puncture  the  minute  wound 
should  be  sequestered  by  a  point  of  Lembert's  suture,  unless 
it  be  intended  to  make  it  the  seat  of  an  enterostomy  opening. 
(Fig.  116.) 

When,  however,  the  dilatation  concerns  the  colon,  and  is 
practically  limited  to  that  bowel,  evacuation  by  puncture 
is  to  be  advised.  If  this  be  made  at  the  summit  of  the 
most  prominent  coil,  it  will  probably  be  shown  to  be,  later, 
the  best  situation  for  an  artificial  anus  ;  and  if  a  good-sized 
trochar  be  used,  it  will  be  found  that  in  most  cases  the 
whole  of  the  larger  bowel  can  be  relieved  by  one  such 
puncture.  In  volvulus  of  the  sigmoid  flexure  the  gigantic 
coil — apparently  filling  the  whole  abdomen — "rhich  is  dis- 
covered in  such  a  case,  can  be  emptied  by  one  puncture. 

If,  then,  in  the  progress  of  the  operation  the  dilated  coils 
are  found  to  be  made  up,  wholly  or  in  the  main,  of  loops 
of  the  colon,  the  most  prominent  coil  should  be  punctured, 
and  after  the  gut  is  evacuated  there  will  be  little  difiiculty 
in  reaching  the  cause  of  the  trouble.  The  puncture  must 
be  guarded  against  leakage,  and  a  temporary,  or  perhaps 
permanent  closure  of  the  little  opening  may  be  indicated. 

In  advising  this  course  when  the  colon  is  concerned,  it 
must  not  be  implied  that  the  incision  in  the  abdominal  wall 


THE    SEARCH   FOR    THE    OBSTRUCTIOX.  487 

is  to  be  of  the  smallest  dimensions.  The  incision  must  be 
as  large  as  is  necessary  to  deal  with  the  condition  without 
unnecessary  handling  of  the  distended  coils. 

When  the  small  intestine  is  concerned,  and  when  it  is 
evident  that  efficient  means  of  investigation  will  not  be 
provided  by  any  evacuation  of  one  or  possibly  two  coils, 
the  bowels  should  be  allowed  to  protrude.  For  this  purpose 
the  incision  must  be  prolonged.  There  must  be  no  stinting 
in  this  direction.  More  patients  have  died  of  a  too  small 
abdominal  incision  than  of  a  too  large  one.  Klimmel  advises, 
in  doubtful  cases,  an  incision  from  the  symphysis  pubis  to  the 
xiphoid  cartilage,  but  such  a  wound  is  certainly  not  called 
for  in  any  ordinary  case.  Very  especial  preparations,  how- 
ever, must  be  made  for  the  reception  of  the  protruding 
bowels.  For  the  covering  of  the  prolapsed  intestines  a  cloth 
is  needed  which  is  of  ample  proportions,  of  periectlj^  smooth 
surface,  and  of  some  thickness.  An  excellent  material  is 
provided  by  two  very  fine  linen  towels,  which  are  used  the 
one  over  the  other.  A  single  towel  does  not  provide  a 
sufficiently  thick  and  substantial  covering  for  the  protruded 
mass.  The  fringed  ends  of  these  towels  should  be  cut  ofV, 
and  the}^  should  be  so  disposed  about  the  parietal  wound 
that  the  bowels  do  not  touch  the  skin ;  do  not,  in  lact,  escape 
beyond  the  towel,  and  are  as  little  as  possible  exposed  to 
the  air.  One  double-towel  may  be  placed  on  one  side  of 
the  wound  and  one  on  the  other,  and  their  margins  may 
be  united  above  and  below  the  extremities  of  the  incision 
by  safety-pins. 

As  the  viscera  protrude  they  are  wrapped  up  from  either 
side.  The  towels  used  should  be  very  well  boiled  before- 
hand, and  should  be  kept  in  the  steriliser  or  in  hot  sterilised 
water  until  required.  They  should  be  wrung  out  as  nearly 
dry  as  possible,  should  be  without  creases,  and  should  be 
of  the  temperature  of  100°  F.  They  are  most  conveniently 
prepared  by  passing  them  through  a  sponge  wringer. 

Free  retraction  of  the  wound  is  necessary,  and,  above  all, 
the  bowels  nmst  be  protected  from  undue  handling  and  undue 
pressure. 

When  the  cause  of  the  obstruction  has  been  discovered 
and  dealt  with,  the  intestines  are  returned.  To  allow  this  to 
be  readily  done  the  Avound  must  be  large.  A  blunt  hook 
is  introduced  into  the  upper  angle  of  the  wound  and  another 
into  the  lower  (if  it  be  not  too  near  the  symphysis).  By 
means  of  these  hooks  the  anterior  abdominal  wall  is  heli 
up.  The  bowels  are  pressed  back  by  the  hands,  the  parts 
being  still  covered  by  the  towels.     The  process  may  be  aided 


488  TREATMENT    OF    ACUTE    OBSTRUCTION. 

hy  retraction  of  the  lateral  parts  of  the  wound,  or  by 
puncturmg  the  bowel  at  a  spot  which  has  been  decided 
upon  as  best  for  the  enterostomy  opening,  should  such  be 
deemed  necessary.  As  a  rule,  however,  any  puncturing  at 
this  stage  is  better  avoided. 

It  must  not  be  assumed  that  in  every  case  it  is  necessary 
to  allow  all  the  dilated  bowels  to  protrude.  Such  a  measure 
is  called  for  in  onl}^  a  few  cases ;  but  the  surgeon,  if  he  is 
disposed  to  allow  any  coils  to  protrude,  should  be  prepared 
to  allow  all  to  escape.  Often  enough,  when  the  most  pro- 
minent coils  have  been  allowed  to  protrude,  it  is  evident 
that  one  is  being  held  back  in  the  abdomen,  and  if  this 
coil  be  folloAved  towards  its  mesenteric  attachment,  the  cause 
of  the  obstruction  may  be  at  once  made  evident. 

The  methods  of  dealing  with  such  forms  of  obstruction 
as  may  be  found  are  considered  in  a  subsequent  chapter. 

The  Establishment  of  an  Opening  in  the  Bowel. — Let 
it  be  assumed  that  the  abdomen  has  been  opened,  and  that 
the  cause  of  the  obstruction  has  been  foimd  and  relieved. 
It  may  be  that  a  band  has  been  discovered  and  divided, 
or  that  a  hernia  has  been  revealed  and  has  been  reduced. 

The  question  arises.  Does  the  operation  end  there,  and 
can  the  abdominal  wound  be  at  once  closed  ?  In  some 
instances  it  may  be;  but,  in  my  opinion,  the  operation  in 
advanced  cases  is  not  completed  until  the  distended  gut 
has  been  evacuated,  and,  consequently,  I  consider  that 
before  the  abdominal  wound  is  sutured  in  such  cases  an 
opening  should  be  made  in  the  bowel  above  the  obstruc- 
tion, so  that  its  contents  may  be  readily  discharged.  By 
"  advanced  cases "  may  be  understood  those  in  which 
the  operation  has  been  delayed  beyond  forty-eight  hours 
from  the  onset  of  the  attack,  and  in  which  there  is  much 
distension  ol  the  abdomen,  with  marked  prostration  and 
stercoraceous  vomiting.  If  the  symptoms  have  been  through- 
out acute,  and  if  the  patient  has  been  well  dosed  with 
morphia,  further  arguments  for  the  opening  of  the  bowel 
are  added.  The  great  indication  for  this  measure  is  an 
engorged  small  intestine,  loaded  and  distended  with  fluid 
contents.  These  contents  are  utterly  noxious,  and  the  bowel 
must  be  freed  from  them. 

The  need,  therefore,  for  the  evacuation  of  the  distended 
bowel  applies  especially  to  cases  in  which  the  small  intestine 
is  involved.  As  a  matter  of  fact  acute  intestinal  obstruction 
usually  implicates  the  lesser  bowel,  and  the  reasons  for  the 
course  just  advised  will  be  evitlent  from  what  has  been 
already  said  in  dealing  with  the  clinical  features  of  the  trouble. 


ESTABLISHING  OF  AN  OPENING  IN  THE  BOWEL.  489 

In  acute  obstruction  wlion  the  symptoms  are  at  all  ad- 
vanced the  real  danger  to  lite  lies  rather  with  the  poisonous 
material  in  the  intestine  than  with  the  actual  obstructing 
cause  beyond  its  ualls.  The  patient  is  dying,  not  because  his 
bowel  is  occluded,  but  because  the  distended  gut  above  the 
obstruction  is  producing  a  poison  which  is  sapping  his 
strength.  It  has  unfortunately  been  too  many  times  demon- 
strated that  the  successful  relief  of  the  obstruction  will 
often  fail  to  save  life,  and,  indeed,  it  is  of  more  moment 
to  relieve  the  patient  of  the  trouble  within  his  bowel  th.^n 
of  that  which  is  without  it. 

This  measure  of  treatment,  by  evacuating  the  gut,  is  by 
no  means  new;  it  was  most  vigorously  advanced  by  Travers 
in  his  remarkable  work  on  the  intestine  which  was  pub- 
lished over  eighty  years  ago.  Travers  supported  his  views 
by  experiments  upon  animals  and  by  the  observation  of 
many  cases  in  the  human  subject,  and  he  elaborated  his 
proposition  by  arguments  which  have  not  been  afiected  by 
the  scientific  advances  of  a  century. 

The  establishment  of  an  artificial  opening  in  the  small 
intestine  is  a  measure  attended  with  risk  although  the  aper- 
ture is,  of  course,  closed  by  a  second  operation  at  the  earliest 
possible  moment.  The  artificial  opening  is  particularly  fatal 
in  the  cases  of  infants  and  young  children,  and  is  to  be 
avoided  in  cases  of  intussusception. 

It  can  be  dispensed  with  also  in  a  great  number  of 
instances  of  acute  obstruction  in  which  the  colon  is  snared, 
especially  if,  in  such  cases,  the  small  intestine  be  free  irom 
fluid  distension.  In  certain  acute  cases  implicating  the  colon 
— as  in  volvulus  of  the  sigmoid  Hexure — an  opening  into 
the  gut  has  to  be  established  for  other  reasons  than  those 
now  under  discussion. 

There  is  no  doubt  whatever  that  the  operation  for  the 
relief  of  a:;ute  intestinal  obstruction  has  been  rendered  in- 
finitely more  successful  since  it  has  become  the  practice  to 
empty  the  bowel  of  its  contents  after  the  obstructing  cause 
has  been  removed. 

I  believe  that  this  addition  to  the  operation  has  reduced 
the  mortality  of  the  measure  by  50  per  cent. 

If  in  any  advanced  case  the  surgeon  fails  to  evacuate 
the  distended  small  intestine  he  has  distinctly  failed  to 
complete  his  operation.  In  hesitating  as  to  the  performance 
of  this  necessary  measure  he  must  remember  that  he  is 
dealing  with  a  case  which  is  absolutely  desperate. 

When  the  obstruction  is  high  up  in  the  lesser  bowel  the 
need  for  oj^ening  the  gut  may  be  avoided  Avhen  there  has 


490  TPxEATMEST    OF   ACUTE    OBSTRUCTIOX. 

been  a  liberal  wasbing  out  of  tbe  stomacb.  To  establish 
an  artiticial  opening  bigb  up  in  tbe  jejunum  is  a  measure 
of  course  very  distinctl}^  to  be  avoided,  and  should  an  ob- 
struction in  this  place  be  discovered  at  the  operation,  the 
contents  of  tbe  gut  may  be  squeezed  back  into  the  stomach 
and  removed  by  washing  out  the  stomach  on  the  operating 
table.  By  such  means  an  enterostomy  may  be  averted,  and 
cases  such  as  these  aftbrd  an  additional  argument  in  favour 
of  the  excellent  measure  of  washing  out  the  stomach  when- 
ever possible. 

The  concluding  of  an  operation  for  acute  obstruction  by 
an  enterostomy  is  very  usually  an  evidence  of  surgical  neglect, 
an  evidence  that  the  operation  has  been  performed  too  late. 
To  avoid  an  enterostomy  in  acute  intestinal  obstruction  the 
abdomen  should  be  opened  at  the  verj^  earliest  possible 
moment.  Every  hour  delaj'ed  adds  to  the  gravity  of  the 
case.  The  one  point  to  be  urged  incessantly  in  these  cases 
is  the  need  for  early  operation.  The  earlier  the  operation 
the  less  the  need  for  an  enterostomy.  Laparotomy  should 
be  performed  at  an  early  enough  period  to  render  an  opening 
into  the  bowel  unnecessar}^ 

The  rule  should  be  this — the  moment  the  diagnosis  is 
made  or  the  condition  of  obstruction  suspected  the  stomach 
should  whenever  possible  be  washed  out  and  the  abdomen 
immediateJy  opened.  AVhen  this  rule  is  recognised  the  need, 
for  the  enterostomy  will  vanish. 

The  best  method  of  performing  enterostomy  when  it  is 
needed  is  by  means  of  a  Paul's  glass  tube  of  suitable  size. 
The  loop  of  gTit  to  be  opened  is  brought  into  position  and 
the  abdominal  wound  is  closed  around  it  until  only  the 
dome  of  the  loop  is  presenting.  The  gut  is  now  secured 
in  place  by  means  of  six  or  eight  sutures  which  involve 
the  whole  thickness  of  the  parietal  wound,  the  peritoneum 
and  the  serous  and  muscular  tunics  of  the  bowel. 

The  gut  is  incised,  the  tube,  blocked  with  cotton  wool,  is 
introduced  and  secured  by  a  single  thread,  which  is  buried  in 
the  groove  around  the  base  of  the  tube.  The  parts  are  dried 
and  well  dusted  with  iodoform.  A  layer  of  cotton  wool  is 
applied,  through  the  centre  of  which  a  hole  is  made  for  the 
tube  to  pass  through.  The  cotton  wool  is  sufficiently  thick 
almost  to  bury  the  vertical  part  of  the  tube.  A  piece  of 
oiled  silk,  or  jaconet,  with  a  hole  in  the  centre,  is  now  applied 
over  the  wool,  the  tube  passing  through  the  aperture  made. 
Finall}^  this  sim23le  dressmg  is  kept  in  place  b}'  a  wide  flannel 
binder,  in  one  part  of  which  a  suitable  aperture  is  made 
for  the  j^assage  of  the  tube.     Over  this  again,  to  protect  the 


COMPLICATION  OF  GANGRENE   OF  THE  BOWEL.    491 

flannel  binder,  another  piece  of  oiled  silk,  or  jaconet,  may  be 
placed,  with  again  a  hole  for  the  tube. 

The  cotton  wool,  the  iodoform,  and  the  lymph  from  the 
exposed  bowel  form  a  species  of  firm  crust,  which  holds  the 
tube  in  place.  The  cotton  wool  plug  having  been  removed, 
the  contents  of  the  gut  are  allowed  to  escape  into  a 
suitable  receiver.  The  contact  of  the  bed-clothes  is  prevented 
by  means  of  a  bed-cradle.  In  from  three  to  five  days  the 
tube  is  loosened  by  the  inevitable  process  of  necrosis,  and  is 
re  iioved  toQfether  with  the  indurated  mass  of  cotton  wool 
which  still  chngs  to  its  base. 

The  after- treatment  of  the  case  is  that  of  a  feecal  fistula, 
and  the  utmost  care  is  needed  to  keep  the  part  constantly 
clean  and  dry. 

In  due  course  this  artificial  opening  is  closed  by  a  second 
operation. 

There  is  nothing  especial  to  be  said  about  the  after- 
treatment  of  these  cases.  It  does  not  differ  from  that 
observed  after  other  abdominal  operations. 

In  the  prostration  which  follows  this  measure,  repeated 
hypodermic  injections  of  strychnia,  together  with  enemata 
containing  alcohol,  will  be  lound  of  much  service. 

The  Complication  of  Gangrene  of  the  Bowel.— When 
the  site  of  the  obstruction  has  been  discovered  it  may  be 
found  that  the  strangulated  bowel  is  already  gaugrenous,  or 
in  such  a  condition  that  any  vitality  it  may  appear  to  possess 
cannot  be  expected  to  be  maintained. 

In  such  a  case  the  bowel  must  be  freed  with  care,  because 
the  actual  line  of  gut  under  the  constricting  agent  may  be 
found  to  be  so  advanced  in  gangrene  as  to  give  way  the 
moment  the  loop  is  set  free. 

The  evidences  of  gangrene  in  the  bowel,  and  the  signs 
which  may  be  taken  to  signify  that  the  gut  is  in  a  pro- 
carious  condition,  or  in  a  state  in  which  its  recovery  is 
speculative,  are  the  same  as  obtain  in  strangulated  external 
hernia?,  and  the  surgical  rules  which  apply  to  that  condition 
apply  precisely  to  the  one  now  under  consideration. 

The  already  gangrenous,  or  suspected  loop  is  drawn 
entirely  out  of  the  abdominal  wound,  the  healthy  gut  on 
either  side  of  the  damaged  part  is  secured  to  the  margins  of 
the  wound  which  are  closed  around  the  two  ends  of  it.  The 
necrosed,  or  necrosing,  bowel  is  now  incised,  and  through  the 
cut  thus  made  the  contents  ot  the  gut  are  allowed  to  escape. 
The  dead  part  of  the  intestine  is  removed  in  the  course  of  the 
next  few  days.  This  is  all  that  may  be  safe  to  do  in  cases  of 
a  severe  and  advanced  type.     In  other  examples,  if  the  state 


492  TREATMENT   OF   ACUTE    OBSTRUCTION. 

of  the  patient  and  the  moderate  extent  of  the  gangrene 
encouraged  it,  the  dead,  or  suspected  bowel,  together  with 
a  V-shaped  portion  of  the  mesentery  connected  therewith, 
may  be  excised,  and,  after  all  bleeding  points  have  been 
secured  and  the  gap  in  the  mesentery  closed  by  a  few 
points  of  suture,  the  divided  ends  of  the  bowel  (which  have 
been  previously  clamped)  are  brought  into  the  narrowed 
parietal  wound  to  form  the  artiticial  anus  which  is  essential 
in  such  cases.  The  two  divided  ends  may  be  connected  by  a 
few  points  of  suture  applied  to  those  portions  of  the  gut 
margins  which  are  about  the  attachment  of  the  mesentery. 

In  cases  in  which  gangrene  exists  experience  is  against 
any  attempt  to  unite  the  divided  ends  of  the  bowel  imme- 
diately after  the  necrosed  portion  has  been  excised. 

Such  a  measure  has  been  carried  out  with  success  in  a  few 
recorded  instances,  but  it  is  a  very  hazardous  proceeding,  and 
neither  the  condition  of  the  patient,  nor  the  state  of  the 
intestine,  would  usually  sanction  this  somewhat  elaborate  and 
possibly  protracted  plastic  operation. 

Operation  during  Peritonitis. — There  was  a  time  when 
the  existence  of  peritonitis  was  supposed  to  contra-indicate 
an}^  operative  interference  in  acute  intestinal  obstruction. 
At  the  present  day  the  question  of  peritonitis  enters  but 
very  little  into  the  problem. 

Peritonitis  i^er  se  is  no  bar  to  the  operation,  and  its  sup- 
posed existence  should  certainl}^  not  cause  an  operation  to 
be  abandoned.  As  a  matter  of  fact  it  is  by  no  means  easy 
to  state  whether  peritonitis  does  or  does  not  exist  in  the 
advanced  stages  of  acute  obstruction. 

In  all  advanced  cases  there  is,  no  doubt,  some  degree 
of  peritoneal  inflammation  present,  and  it  is  coincident  with 
that  general  septic  condition  which  tends  to  become  more 
and  more  pronounced  as  time  advances. 

If  a  really  extensive  peritonitis  of  the  usual  low  type 
exists  the  case  is  practically  hopeless  with,  or  without,  an 
operation.  The  bowels  are  much  distended,  are  paralysed, 
and  are  unable  to  empty  themselves  when  drained ;  the 
condition  of  the  patient  also  is,  most  probably,  one  of  rapidly 
increasing  septicaemia.  In  such  a  case  an  operation,  if 
.  declined  as  hopeless,  would  be  declined  not  on  account 
of  any  peritonitis  Avhich  may  be  present,  but  on  account  of 
the  deplorable  condition  of  the  patient. 

It  may  be  said  that  when  peritonitis  is  found  to  exist, 
the  more  brisk  and  more  active  its  manifestations  the  more 
bright  are  the  prospects  of  the  operation.  The  cases  which 
are  the  least  satisfactory  are  those  associated  with  that  low 


OrERATION   DURING    PERITONITIS.  493 

type  of  general  peritonitis  which  presents  but  feeble  mani- 
festations, and  which  is  a  more  or  less  inevitable  feature  in 
the  last  stages  of  any  case  of  fatal  intestinal  obstruction. 

Many  examples  of  successful  operation  for  acute  obstruction 
associated  with  pronounced  peritonitis  have  been  recorded.  I 
might  select  two — one  performed  in  the  early  daj^s  of  antiseptic 
surgery,  and  one  in  quite  recent  years.  The  first  case  was 
recorded  by  M.  Terrier.  It  concerned  a  female,  aged  twent}^- 
one,  who  was  operated  upon,  upon  the  third  day  of  the 
symptoms,  for  the  relief  of  a  strangulation  by  a  band.  Much 
sero-sanguinolent  fluid  escaped  from  the  peritoneal  cavity,  the 
serous  membrane  was  red,  and  the  intestines  extensively 
adherent  by  soft  recent  adhesions.  The  band  was  found  and 
divided  without  difficulty."^  The  patient  made  a  complete 
recovery. 

In  the  second  case,  reported  by  Mr.  Robert  Jones,  the 
patient  was  a  girl  of  fourteen.  Symptoms  of  intestinal 
obstruction  had  existed  for  twelve  days.  The  vomited  matter 
was  stercoraceous.  A  broad  band  was  discovered  and  divided. 
Peritonitis  was  present  as  shown  by  the  numerous  adherent 
coils.     The  patient  did  well.f 

In  connection  with  this  subject  one  can  only  repeat  that 
the  existence  of  peritonitis  does  not  per  se  affect  the  question 
of  operation,  that  measure  being  decided  upon  more  general 
grounds  than  those  concerned  with  this  one  pathological 
condition  or  accident. 


*  Bull,  et  Me\a.  de  la  Soc.  de  Chir.  de  Paris,  1879,  p. 
fBfit.  A'ed.  Journ.,  vol.  i.,  1894,  p.  1123. 


5G4. 


404 


CHAPTER  III. 

THE  OPERATIVE    TREATMENT    OF    PARTICULAR    FORMS 
OF    ACUTE    INTESTINAL    OBSTRUCTION. 

A.  Strangulation  by  Bands  or  through  Apertures, 
ETC. — Under  this  heading  are  inchided  the  following  conditions: 
(1)  strangulation  by  peritoneal  bands ;  (2)  by  omental  cords; 
(8)  by  Meckel's  diverticulum  or  a  diverticular  ligament :  (4) 
by  an  adherent  vermiform  appendix,  Fallopian  tube,  etc.  ; 
(5)  strangulation  through  slits  and  apertures ;  (6)  internal 
herniae;  and  (7)  certain  rare  cases  of  kinking  of  the  small 
intestine,  or  sudden  blocking  of  it  by  the  displacement  of 
a  tumour  outside  the  gut. 

I,  2.  Strang-ulation  by  Bands  and  Omental  Cords. — Yery 
slender  bands  may  be  torn.  When  more  substantial  they 
are  divided  between  two  ligatures.  Bands  should  be  cut  as 
short  as  possible  in  order  that  they  may  give  no  further 
trouble.  Membranous  bands  ma}^  need  to  be  cut,  and  any 
vessels  thereby  exposed  to  be  separately  ligatured. 

Great  care  should  be  observed  in  separating  adhesions 
from  the  bowel,  lest  the  bowel  be  torn,  an  accident  which 
has  frequently  happened.  Any  small  raw  surface  left  by  the 
separation  of  adhesions  ma}^  be  sequestered  by  a  few  points  of 
suture,  should  bleeding  persist.  Bleeding  vessels  on  such 
raw  surface  which  cannot  be  ligatured,  may  be  secured  by 
stitching.  A  milliner's  needle  and  fine  silk  are  the  best 
materials  for  these  little  operations,  which  are  illustrated  by 
the  accompanying  diagrams  (Fig.  116).  The  bleeding  depend- 
ing upon  the  sej)aration  of  adhesions  is  usuall}^  slight,  and 
Aviil  for  the  most  part  subside  on  exposure  to  the  air  followed 
by  suitable  pressure. 

Fine  omental  cords  may  be  divided  between  two  ligatures. 
They  also  should  be  cut  as  short  as  possible. 

Some  omental  cords  are  very  substantial  and  very  vascular, 


OVEBATION    FOB    STRANGULATION   BY    BANDS.    495 


and  may,  indeed,  consist  of  the  whole  or  one-half  of  the 
omentum  rolled  up  into  a  large  band.  Such  cords  should  be 
ligatured  in  small  sections  with  tine  silk.  Or  they  may  be 
clamped  and  divided  and  the  individual  vessels  secured.  The 
former  plan  is  the  safer  and  in  ihe  end  the  shorter. 

8,  4.  Strang-ulation  by  Meckel's  Diverticulum,  or  by 
Adherent  Structures. — Diverticular  ligaments  are  treated 
in  the  same  way  as  peritoneal  bands. 

When  the  diverticulum  persists  as  a  small  hollow  tube  it 

should    be   divided   and    the  — • 

end  secured  by  a  circular 
ligature.  The  cut  end  should 
then  be  sequestered  by  means 
of  one  or  more  points  of 
Lembert's  suture  whenever 
possible. 

When  a  fu]l-si;5ed  diver- 
ticulum exists,  it  should  be 
divided  at  its  distal  extremity 
or  narrowest  point.  This 
part  should  be  sutured,  any 
exposed  mucous  meuibrane 
cut  away,  and  the  divided 
surface  sequestered  by  means 
of  one  or  more  points  of 
Lembert's  suture,  as  is  done 
in  excising  the  vermiform 
appendix. 

It  is  undesirable  to  attempt 
to  excise  the  full-sized  diver- 
ticulum. The  excision  of  such 
a  process  leaves  a  large  hole 
in  the  bowel,  which  has  to  be 
closed  by  very  careful  suturing. 

The  urgency  of  the  patient's  condition  and  the  unwholesome 
condition  of  the  bowel  are  very  unfavourable  for  a  tedious 
plastic  operation.  If  a  large  diverticulum  be  gangTenous — as 
it  is  now  and  then — it  must  be  brought  out  of  the  wound  and 
the  segment  of  bowel  concerned  be  used  for  the  enterostomy 
opening  which  will  be  inevitable. 

There  is  no  time  available  in  laparotomy  for  acute 
obstruction  for  other  measures  than  such  as  are  absolutely 
unavoidable. 

When  the  obstruction  is  caused  by  an  adherent  vermiform 
appendix,  the  appendix  had  better  be  removed.  The  excision 
occupies  but  a  few  minutes. 


Fig.  116. — The  three  upper  figures  show 
the  sequestering  of  a  raw  bleeding 
surface,  A.  The  lower  figure  shows 
the  securiug  of  a  bleeding  point,  B,  by 
stitching. 


49G     OPEBATION  FOB   8TBANGULATI0N  BY  KINKING. 

An  adherent  Fallopian  tube  should  be  set  free  from  its 
adhesions,  and  in  certain  circumstances  its  removal  may 
be  advisable. 

5,  6.  Strangulation  through  Slits  and  Apertures  and 
Internal  Hernia.— The  slit  or  opening  causing  the  obstruction 
must  be  enlarged  in  order  that  the  strangulated  bowel  may 
be  withdrawn.  In  effecting  such  enlargement  ^reat  care 
must  be  taken  that  no  vessels  are  divided  and  their  division 
overlooked.  Blood-vessels  often  surround  the  slits  in  the 
mesentery,  and  the  disposal  of  blood-vessels  about  the 
orifices  of  internal  hernia  has  been  already  noted  (page  112). 
Slits  and  rents  in  the  omentum  or  mesentery,  or  in  any  wide 
nlembranous  adhesions,  should  be  closed  by  a  few  points  of 
suture. 

Slits  in  adhesions  may  probably  be  dealt  with  best  by  the 
division  of  the  whole  adhesion. 

The  sacs  of  internal  hernise,  if  well  divided  and  opened  up, 
will  probably  cease  to  give  further  trouble  (page  115). 

I  have  reported  a  case  of  strangulated  hernia  at  the 
Foramen  of  Winslow  upon  which  I  operated,  but  was  unable 
to  liberate  the  bowel.  At  the  autopsy  I  could  not  set  the 
bowel  free  until  I  had  divided  the  hepatic  artery,  the  portal 
vein,  and  the  common  bile  duct  (page  117). 

7.  Strangulation  by  Kinking,  etc. — The  cases  which  come 
under  this  heading  cannot  be  dealt  with  by  any  stereotyped 
plan.  They  are  not  likely  to  present  any  particular  difficulty 
and  each  case  must  be  dealt  with  on  its  merits. 

After  an  obstructing  band  has  been  relieved,  care  should 
be  taken  to  ascertain  that  there  is  no  other  occluding  cord. 
I  might  refer  to  two  instances  where  there  were  two  bands 
causing  obstruction  in  one  case.  In  each  instance  laparotomy 
was  performed  and  one  band  was  divided,  and  in  each 
instance  it  was  the  wrong  band,  or  the  one  causing  the  less 
serious  obstruction.     Both  patients,  of  course,  died."^ 

Dr.  Maylardt  has  collected  thirty-three  cases  of  successful 
operation  for  internal  strangulation  of  the  type  now  under 
notice.  The  operations  were  all  performed  during  the  years 
from  1891  to  1895  (inclusive).  The  average  period  between 
the  onset  of  the  symptoms  was  five  days  seven  hours,  the 
two  extreme  periods  being  fifteen  hours  and  twelve  days 
respectively.  In  one  case  only  was  an  artificial  anus  formed. 
In  one  case  four  inches  of  bowel  were  resected. 

B.  Volvulus. — In  most  cases  the  volvulus  concerns  the 
Bigmoid  flexure.     A  sufficiently  large  incision  must  be  made 

*  Lancet,  vol.  i.,  1876,  p.  773;  and  ibid.,  vol.  i.,  1873,  p.  773. 
t  The  Surgery  of  the  Alimentary  Canal,  Lond.,  1896,  p.  363. 


OPERATION   FOB.    VOLVULUS.  497 

to  expose  the  loop,  or  at  least  the  greater  part  of  it.  The 
bowel  should  then  be  opened  and  evacuated  of  its  contents. 
The  opening  thus  made  should  be  used  as  the  opening  of  an 
artificial  anus,  the  gut  being  properly  secured  in  place. 

In  some  cases  the  distended  loop  has  been  reduced  with 
or  without  a  preliminary  tapping.  The  parietal  wound  has 
been  closed  and  the  case  has  done  well. 

Such  an  experience  is,  however,  unconnnon,  and  is  mostly 
limited  to  volvulus  of  the  small  intestine.  Maylard"^  has 
collected  six  cases  of  the  successful  treatment  of  volvulus  ot 
the  small  intestine  by  operation.  In  two  the  trouble  was  due 
to  a  gall  stone,  and  in  one  there  was  a  large  mesenteric 
lipoma. 

In  all  the  bowel  was  simply  untwisted,  and  no  recur- 
rence took  place.  In  the  case  of  the  lipoma  the  tumour 
was  removed. 

If  any  part  of  the  gut  be  gangrenous,  in  such  cases  the 
affected  loop  must  be  drawn  well  out  of  the  wound,  and, 
whether  it  he  there  and  then  removed  or  left,  an  artiiicial 
anus  must  be  established. 

Several  cases  are  recorded — as  has  just  been  noted— in 
which  a  volvulus  of  the  sigmoid  flexure  has  been  reduced 
after  the  loop  had  been  evacuated.  The  hole  made  in  the 
gut  had  been  closed,  and  the  parietal  wound  sutured.  A  good 
example  of  such  an  operation  is  provided  by  Dr.  William 
Mayo.t  Other  successful  cases  are  recorded  by  McArdle,:!^ 
Senn,§  Finney,  ||  Benham,^  and  Little wood."^^ 

Mr.  Littlewood's  cases  are  worthy  of  notice  as  they  all 
occurred  in  the  practice  of  one  surgeon.  He  gives  details  of 
seven  cases  of  volvulus  in  which  he  had  performed  abdominal 
section  during  three  years ;  there  were  three  recoveries :  (1) 
Man,  aged  sixty-two,  volvulus  of  large  intestine,  involving  part 
of  transverse  colon,  descending  colon,  and  part  of  sigmoid ;  the 
volvulus  was  ten  inches  in  diameter,  and  displaced  the  heart 
upwards  into  the  third  intercostal  space ;  operation  performed 
five  days  after  onset  of  acute  symptoms;  death  thirty  hours  later. 
(2)  Man,  aged  sixty-one,  volvulus  of  caecum,  part  of  ascending 
colon  and  part  of  ileum;  the  volvulus  was  about  five  inches 
in  diameter ;  operation  five  days  after  onset ;  recovery.  (3) 
Woman,  aged  fifty-seven,  volvulus  ofjiigmoid  fiexure ;  operation 

*  Loc.  cit.,  p.  392. 

t  Annals  of  Surgery,  18t)3,  vol.  xviii. ,  p.  28. 

X  Buhlni  Journ.  of  the  Med.  Sc,  1893,  p.  97. 

§  Annual  of  the  TJniversal  Med.  Sciences,    1891,  \o\  iii.,  C-37. 

il  Ibid.,  1894,  C-26. 

i  Trans.  Clin.  Soc,  Lond.,  189;'),  p.  180. 

«*  Brit.  Med.  Joiirn.,  vol.  ii.,  189S.  p.  1820. 

G  G 


498  OPEEATION   FOR    VOLVULUS. 

six  days  after  acute  onset ;  death  forty  hours  later.  (4)  Girl, 
aged  eleven,  volvulus  of  sigmoid  flexure ;  operation  thirtj^-six 
hours  after  acute  onset;  general  distension  with  peritonitis; 
recovery.  (5)  Woman,  aged  thirty-two,  volvulus  of  small  intes- 
tine about  ten  inches  in  length.  Acute  symptoms  started  about 
three  weeks  after  confinement ;  operation  six  days  after  onset. 
General  peritonitis  with  stinking  blood-stained  fluid  in  peri- 
toneal cavity.  The  twisted  portion  of  the  bowel  was  deeply  con- 
fested  and  adherent  b}^  soft  adhesion  to  the  surrounding  bowels, 
'elvis  drained,  the  lower  part  of  the  wound  not  closed,  and  the 
twisted  portion  of  bowel  brought  near  the  opening.  Thirteen 
days  later  the  volvulus,  which  had  become  gangrenous, 
separated  and  was  removed.  Two  months  later  the  intestinal 
fistulse  were  closed  by  separating  the  parts  from  adhesions 
and  suturing  the  upper  and  lower  portions  of  boAvel  together. 
Patient  made  a  good  recovery.  (6)  Man,  aged  fifty-three  ; 
volvulus  of  small  intestine  involving  several  feet ;  operation 
five  days  after  onset;  death  six  days  later.  (7)  Man,  aged 
twenty  ;  volvulus  of  small  intestine  about  two  feet  in  length  ; 
tuberculous  mesenteric  glands  and  adhesions ;  three  days 
after  onset  operation  performed ;  death  four  days  later. 

Mr.  Greig  Smith"^  reports  a  successful  operation  for  vol- 
vulus of  the  sigmoid  flexure  in  a  man  of  eighty-five. 

Unless  some  special  means  are  taken  the  volvulus  is  very 
apt  to  return.  Koux  has  performed  three  operations  upon 
the  same  patient  on  account  of  relapses,  and  for  the  same 
reason  Obalinski  has  had  to  carry  out  a  second  operation  in 
no  less  than  four  cases  of  volvulus. 

An  artificial  anus,  established  temporarily,  is  perhaps,  on 
the  whole,  the  best  means  of  preventing  such  recurrence. 

Rouxf  recommends  that  to  avoid  a  recurrence  the  sigmoid 
mesocolon  should  be  sutured  to  the  abdominal  wall,  and 
Gouldj  has  fixed  the  bowel  itself  to  the  parietes  to  effect 
the  same  end.  Obalinski  has  suggested  the  resection  of 
the  loop. 

In  any  case  there  may  be  considerable  difficulty  in  the 
reduction.  In  one  instance  I  could  not  untwist  a  volvulus  of 
the  sigmoid  flexure  through  the  wound,  nor  could  I  reduce 
it  at  the  autopsy  until  after  much  disturbance  of  parts. 

Mr.  Greig  Smith  mentions  that  at  an  autopsy  Avhich  he 
performed  on  a  case  of  volvulus  of  the  csecum  he  could  not 
undo  the  twist,  although  the  incision  extended  from  the 
Bternum  to  the  os  pubis. 

*  £rot.  Mai.  Journ.,  July  20.  1895. 
t    CentralhMt  fih-  C}iir.,  1898,  p.  800. 
I  Jirit  Med.  Jonr/i.,  1895,  vol.  i.,  p.  979. 


TREATMENT    OF   ACUTE    INTUSSUSCEPTION.        499 

In  several  instances  no  reduction  was  possible  until  the 
whole  of  the  volvulus  had  been  allowed  to  protrude  through 
the  abdominal  wound. 

Mr.  Greig  Smith  mentions  a  case  of  volvulus  of  the  small 
intestine  which  he  managed  to  reduce  by  operation.  In  seven 
days,  however,  it  recurred,  when  by  a  second  operation  a 
small  opening  was  made  in  the  bowel,  which  it  was  found 
necessar}''  to  keep  patent  for  nearly  a  year. 

In  a  case  of  volvulus,  dealt  with  primarily,  a  simple  open- 
ing into  the  bowel,  without  a  definite  untwisting  of  the  loop  is, 
of  course,  not  to  be  advised. 

There  are  several  cases  of  such  a  partial  measure  on  record, 
and  they  have  not  been  successful. 

If  gangrene  of  the  bowel  be  present  it  must  be  dealt  with 
on  the  lines  already  indicated  (page  491). 

It  has  been  suggested  that  in  some  cases  of  volvulus  a 
lateral  anastomosis  may  be  established  at  the  neck  of  the 
twisted  parts  of  the  bowel.  I  am  not  aware  that  this  measure 
has  been  carried  into  practice,  and  the  probable  condition  of 
the  bowel  in  an  acute  case,  would  render  the  performance  of 
such  an  operation  of  very  doubtful  value. 

The  resection  of  the  twisted  loop  has  also  been  advised, 
not  only  as  an  immediate  measure  of  treatment,  but  also  to 
prevent  recurrence.  Such  an  operation  would,  however,  not 
be  advisable  in  a  really  acute  case,  and  in  any  instance  it 
could  be  only  applied  to  examples  in  which  the  volvulus 
was  very  small.  The  smaller  varieties  of  volvulus  are  capable 
of  being  treated  by  simpler  measures.  It  must  be  remem- 
bered that  the  loop  concerned  in  a  volvulus  of  the  sigmoid 
flexure  may  be  literally  enormous,  and  may  appear  when 
exposed  to  occupy  the  whole  of  the  abdomen.  The  summit 
of  such  a  loop  is  often  found  to  be  pressing  up  the  liver. 

C.  Acute  Intussusception.— The  patient  is  placed  in  bed 
and  is  kept  warm  Brandy  ma}^  be  administered  if  there  be 
much  collapse.  The  bed-clothes  may  be  kept  from  coming  in 
contact  with  the  surface  of  the  abdomen  b}^  means  of  a  bed- 
cradle,  in  the  case  of  adults.  Morphia  or  opium  should  be 
administered  at  once.  The  quantity  given  must  be  the  least 
amount  required  to  ease  the  pain,  to  arrest  peristaltic  move- 
ment, and  to  bring  about  a  state  of  peace  within  the  abdomen. 
So  long  as  these  ends  are  effected,  the  smaller  the  quantity 
given,  and  the  less  frequently  the  dose  is  repeated,  the  better. 

In  acute  cases  in  which  time  has  been  allowed  to  elapse 
before  the  child  receives  any  medical  attention,  an  anaesthetic 
may  be  administered  at  once,  and  no  more  time  wasted  to 
observe  the  effect  of  morphia. 


500        TUEATMENT    OF   ACUTE    INTUSSUSCEPTION'. 

Aperients  of  any  kind  are  to  be  most  absolutely  avoided 

The  amount  of  food  given  by  the  mouth  must  be  reduced 
to  a  minimum  and  will  consist  of  minute  quantities  of  hot 
water  or  (in  adults)  hot  weak  tea  or  peptonised  milk  and  hot 
water,  or  barley  water.  Thirst  can  generally  be  relieved  by 
Avater  administered  by  the  mouth.  If  incessant  vomiting  be 
present  all  feeding  by  the  mouth  must  be  discontinued.  As 
early  operative  interference  is  indicated  in  these  cases  the 
question  of  prolonged  feeding  does  not  arise,  nor  has  the 
surgeon  to  give  much  attention  to  the  problem  of  keeping  up 
the  patient's  strength. 

As  warm  applications  to  the  abdomen  often  give  consider- 
able relief  they  may  take  the  form  of  sterilised  towels  soaked 
in  1  in  30  or  1  in  40  carbolic  solution  made  as  warm  as  the 
patient  can  comfortably  bear  it. 

A  few  instances  are  recorded  in  which  rest  and  morphia 
combined  with  abstinence  from  food  have  led  to  the  reduction 
of  the  intussusception.  Such  a  result  is,  however,  very  un- 
common and  is  not  in  any  way  to  be  depended  upon.  If  such 
good  fortune  should  befall  the  patient  the  improvement  may 
be  expected  to  be  apparent  as  soon  as  the  morphia  has  taken 
effect.  The  fact  that  cases  of  cure  have  been  met  with 
after  no  more  elaborate  treatment  than  that  mentioned 
must  not  afford  any  excuse  for  persisting  in  these  elementary 
measures.  They  only  serve  to  indicate  that  the  sooner 
the  patient  is  brought  under  the  influence  of  morphia  the 
better. 

Bloodless  Methods. — Under  the  title  of  the  bloodless 
methods  of  treating  intussusception  the  following  procedures, 
good  and  bad,  are  included.  1.  Manipulation  of  the  tumour, 
either  with  or  Avithout  an  anaesthetic.  2.  "  Abdominal  taxis," 
including,  possibly,  the  inversion  of  the  body.  3.  Electricity. 
4.  The  use  of  copious  enemata.  5.  Insufflation  with  air  or 
with  certain  gases. 

1,  2,  3.  The  first  three  of  these  measures  call  for  little 
comment  and  have  nothing  to  recommend  them.  Manipula- 
tion of  the  tumour  is  a  mere  groping  in  the  dark  and  is  as 
likely  to  do  harm  as  good.  In  any  case  which  is  at  all 
advanced  this  treatment  is  more  apt  to  be  attended  by  disaster 
than  by  improvement.  Abdominal  taxis,  with  possible  inver- 
sion of  the  body,  needs  only  to  be  mentioned  to  be  condemned. 
As  a  measure  of  serious  treatment  it  can  only  be  spoken  of  as 
stupid.  The  evidence  that  intussusceptions  have  been  reduced 
by  the  use  of  electricity  is  very  questionable.  The  measure 
appears  to  have  done  little  more  than  afford  an  excuse  for 
wasting  time.      The  pathology  of  the  disease  would  suggest 


FORCIBLE    ENEMATA.  501 

that  the  passage  of  an  electric  current  along  the  bowel — ^should 
such  a  proceeding  be  possible — would  add  to  the  severity  of 
the  invagination  rather  than  tend  to  unfold  it. 

4.  Forcible  Enemata. — Intussusceptions  which  have  in- 
volved the  colon,  or  which  have  entered  that  bowel,  may  be 
reduced  by  means  of  fluids  forcibly  introduced  into  the  rectum 
or  by  the  insufiiation  of  certain  gases  made  to  enter  through 
the  same  passage.  It  may  be  said  at  once  that  the  injection 
of  fluid  is  preferable  to  inflation.  Fluid  represents  a  more 
powerful  and  solid  reducing  force,  and  its  employment  can 
be  graduated  with  greater  accuracy. 

"  Many  observers,"  writes  Mr.  D'Arcy  Power,  "  have  shown 
by  experiments  on  living  and  on  dead  bodies  that  fluid  can 
only  be  made  to  pass  through  the  ileo-csecal  valve  when  over- 
distension of  the  colon  has  caused  a  mechanical  separation  of 
its  two  segments.  Such  an  over- distension,  however,  is  in  the 
highest  degree  dangerous,  because  it  is  usually  accom^^anied 
by  a  cracking  of  the  serous  coat  of  the  large  intestine,  which 
is  soon  followed  by  rupture  of  the  muscular  and  mucous  layers 
if  the  force  be  continued." 

In  spite  of  instances  in  which  intussusceptions  have  been 
reduced  by  enemata  after  long  periods  of  time,  experience 
shows  that  this  measure,  to  be  successful,  must  be  employed 
at  the  earliest  possible  moment  after  the  onset  of  the  trouble, 
and  that  it  is  not  likely  to  succeed  in  acute  cases  when  more 
than  forty-eight  hours  have  elapsed  since  the  commence- 
ment of  the  attack.  (The  contra-indications  are  given  on 
page  506.) 

The  fluid  usually  employed  is  the  ordinary  salt  solution 
at  a  temperature  of  100''  F.  (one  teaspoonful  of  salt  to  the 
quart). 

The  amount  that  has  been  introduced  in  cases  of  success- 
ful reduction  varies  considerably.  In  at  least  two  recorded 
examples  of  success  in  infants,  eight  ounces  sufliced.  In 
another  case  three  quarts  of  fluid  under  a  head  of  five  feet 
were  injected  into  the  bowel  of  an  infant  seven  and  a  half 
months  of  age.  One  injection  may  suffice^  or  reduction  may 
be  accomplished  after  three,  four,  or  five  enemata.  In  one 
recorded  case  no  less  than  nine  enemata  were  required  to 
bring  about  a  permanent  reduction  of  the  invagination.* 
The  patient  was  a  male  infant  aged  four  months.  Such 
repeated  attempts  at  reduction  by  injection  are  not  to  be 
commended. 

There  is  evidently  a  considerable  difl'erence  in  the  amount 
of    fluid   the    colon   will    accommodate    in    infants    as    the 

*  Dr.  Andrew  ;    St.  Bart.'s  Hosp.  Reports,  1892. 


502         TREATMENT    OF    ACUTE    IXTUSSUSGEPTION. 

following  results  of  an  inquiry  by   Mr.  D'Arcy  Power^  will 
show. 

Male         .         .       ;")  months     Capacity  of  colon  10  oz. 


Male 

5 

)) 

13i„ 

Female     . 

7 

)) 

30   „ 

Female     . 

9 

)» 

16   „ 

Male 

.      15 

'9 

28   „ 

Female     . 

.      10 

years 

"9   „ 

Female     . 

.      14 

55 

40   „ 

The  fluid  is  best  introduced  into  the  colon  by  means  ol 
hydrostatic  pressure  which  allows  of  its  entering  the  bowel  by 
its  own  weight.  Enemata  given  by  an  ordinary  enema  syringe 
are  unsatisfactory.  The  fluid  is  introduced  in  jerks  and  the 
amount  of  force  employed  is  difficult  to  estimate. 

In  employing  irrigation  a  piece  of  rubber  tubing  is  pro- 
vided. To  one  end  the  nozzle  of  an  enema  syringe  is  attached, 
while  the  other  end  is  connected  with  a  glass  funnel.  The 
nozzle  is  introduced  into  the  anus,  and  a  measured  quantity 
of  salt  solution  is  then  poured  through  the  funnel  which 
should  be  raised  to  the  height  of  three  feet  above  the  level  of 
the  patient's  body.  It  is  desirable  that  the  patient  should  be 
anaesthetised  during  the  process.  The  fluid  should  be  allowed 
to  remain  in  the  colon  for  at  least  ten  minutes  before  it  is 
permitted  to  escape.  The  surgeon's  hand  should  rest  upon  the 
abdomen  during  the  process  of  the  irrigation.  No  manipula- 
tion of  the  belly  is  required  beyond  such  as  is  necessary  to 
examine  the  tumour. 

Nothing  is  to  be  gained  by  the  inversion  of  the  patient 
during  the  irrigation,  but  the  head  should  be  placed  low  and 
the  whole  pelvis  raised  upon  a  hard  cushion  while  the  fluid 
is  entering. 

Experience  shows  that  long-continued  distension  under  a 
low  pressure  is  of  more  avail  than  rapid  distension  under  a 
high  pressure. 

If  no  improvement  follows  upon  the  tirst  imgation  it  is 
useless  to  repeat  it.  An  immediate  laparotomy  should  be 
carried  out 

As  to  the  amount  of  fluid  which  should  be  introduced,  Dr. 
Wiggin  t  concludes  after  a  full  investigation  of  the  subject 
that  in  the  case  of  an  infant  at  least  one  pint  and  a  half  ol 
fluid  may  be  placed  in  the  funnel,  the  elevation  of  which  will 
not  exceed  three  feet.  The  amount  of  this  fluid  which  will 
enter  the  bowel  must,  of  course,  vary  in  dift'erent  cases. 

Rupture  of  the  bowel  may  readily  or-r-ur  if  the  amount  of 
pressure  employed  be  too  great. 

*  -Edin.  Med.  Jo>rr>>..  June  1807. 

■^  Kew  YorJc  Med.  Record,  Jan.  18,  1896. 


FORCIBLE    ENEMATA.  503 

Upon  this  point  I  cannot  do  better  than  quote  the  remarks 
made  by  Mr.  D'Arcy  Power  in  his  Hunterian  lectures  dehvered 
at  the  Koyal  College  of  Surgeons  in  1897.^ 

"  The  valuable  experiments  of  Mr.  Mortimerf  in  London  and 
Mr.  Molet  in  Bristol  have  greatly  increased  our  scientific  knowledge  of 
the  eflects  of  irrigation  in  the  treatment  of  intussusception.  They 
have  shown  that  the  results  depend  partly  upon  the  obstruction  to  be 
overcome  within  the  intestine  and  partly  upon  the  external  support. 
The  greater  the  pressure  within  the  abdomen  the  more  is  the  dis- 
tending force  neutralised,  for  the  intestinal  wall  is  then  compressed 
between  two  opposing  forces.  Mr.  Mortimer  experimenting  upon  the 
unopened  bodies  of  children,  points  out  that  in  an  irreducible  intus- 
susception the  large  intestine  is  distended  by  almost  the  whole  force  of 
the  stream  when  the  abdominal  walls  are  lax,  as  is  usual  in  children 
under  chloroform,  and  when  there  is  not  much  tympanites.  The 
intestine  may  kink  if  fluid  be  allowed  to  enter  the  bowel  too  suddenly 
or  too  forcibly,  and  the  distending  force  is  then  prevented  from  acting 
upon  the  intussusception,  so  that  the  colon  may  become  sufficiently 
over-distended  to  rupture.  A  similar  accident  may^ happen  as  a  result 
of  a  sudden  peristaltic  contraction  taking  place  whilst  the  pressure  is 
being  applied.  There  is  apt  to  be  cracking  of  the  serous  coat  of  the 
large  intestine  when  the  resultant  pressure  of  the  fluid  distending  the 
colon  is  about  two  and  a  half  pounds— that  is  to  say,  when  the  irrigator 
is  raised  five  feet  above  the  body  of  the  patient,  and  this  accident 
usually  happens  when  the  irrigator  is  raised  to  eight  feet,  though  the 
bowel  may  be  completely  ruptured  when  the  reservoir  is  only  raised  to 
a  height  of  six  feet. 

"Mr.  Mole  used  a  slightly  different  method  of  experiment,  but  he 
arrived  at  substantially  the  same  results,  and,  as  he  worked  with  the 
abdomen  open,  he  was  able  to  see  the  exact  manner  in  which  the 
intestine  ruptured  as  a  result  of  its  over-distension.  When  this  accident 
is  imminent  the  peritoneal  coat  of  the  bowel  splits  longitudinally  for  a 
considerable  length  ;  the  fluid  then  begins  to  leak  through  the  wall  of 
the  gut,  a  small  jet  issues,  and  at  last,  if  the  pressure  be  continued,  a 
large  rent  takes  place,  with  forcible  expulsion  of  the  contents  of  the 
bowel  into  the  peritoneal  cavity. 

"Rupture  of  the  large  intestine  is  most  likely  to  occur  in  the  trans- 
verse colon,  at  or  near  to  the  splenic  flexure,  whilst  in  the  small 
intestine  it  takes  place  in  the  unprotected  portion  of  the  bowel  which  is 
situated  between  the  two  layers  of  the  mesentery. 

"  It  should  be  borne  in  mind,  however,  that  these  results  are  derived 
from  experiments  upon  dead  bodies  and  upon  animals.  It  is  impossible 
for  the  surgeon  to  estimate  the  capacity  of  the  colon  in  any  individual 
case  of  intussusception,  nor  can  he  judge  the  amount  of  pressure  that 
may  be  applied  with  safety  to  the  inflamed  and  softened  intestinal  wall 
at  the  neck  of  the  tumour.  A  pint  of  fluid  was  sufficient  to  rupture  the 
bowel  in  a  child,§  aged  three  months,  though  the  injection  was  made  by 
one  of  the  most  careful  and  experienced  surgeons  in  the  profession  ; 
whilst  in  another  child,  1|  aged  seven  and  a  half  months,  three  quarts 

*  Brit.  Med.  Journ.,  Feb.  13,  20,  27.  1897. 

t  Lancet,  vol.  i.,  1891,  p.  1144. 

X  Bristol  Med.  C'hir.  Jouni,.  1894.  p.  6.5. 

§  Trans.  Clin.  Soc,  1888,  p.  244. 

II  Mtc  York  Med.  Record.  1S99,  p.  83.     I>r.  "WiVgin. 


504         TREATMENT    OF   ACUTE    INTUSSUSCEPTION. 

under  a   head  of  live  feet  pressure  were  injected  into  the  intestinal 
canal  without  doing  any  injury." 

Mr.  Knaggs  "^  gives  an  account  of  seven  cases  in  which 
rupture  of  the  bowel  took  place.  In  six  of  these  the  ages  were 
from  five  to  seven  months.  In  one  only  nine  ounces  of  Avater 
Avere  injected. 

"  A  sudden  and  uniform  enlargement  of  the  whole 
abdomen,"  continues  Mr,  Power,  "  raises  a  strong  suspicion 
that  the  bowel  has  been  ruptured,  because  rupture  of  the 
colon  almost  always  takes  place  before  there  is  any  great 
distension  of  the  small  intestine.  A  laparotomy  must  be 
done  at  once  when  this  accident  happens,  and  the  seat  of 
rupture  should  be  looked  for  either  on  the  left  side  of  the 
abdomen  or  at  the  neck  of  the  intussusception." 

The  length  of  the  intussusception  is  no  bar  to  its  reduc- 
tion by  irrigation,  for  many  cases  are  recorded  in  which  an 
intussusception  has  been  reduced  even  when  the  ileo-csecal 
valve  has  protruded  beyond  the  anus,  and  Dr.  Mansel 
Sympsont  cured  a  case  by  this  means  when  six  inches  of 
the  intestine  were  visible  externally. 

Unfortunately  after  an  apparently  successful  reduction 
of  an  intussusception  by  distension  a  relapse  is  very  liable 
to  occur,  and  the  invagination  to  form  again.  It  is  probable 
that  in  a  large  number  of  these  cases  complete  reduction 
never  was  effected,  and  that  the  instances  are  not  examples 
of  genuine  relapse. 

Barker  J  gives  details  of  til  teen  cases  of  acute  intus- 
susception treated  by  himself  within  the  last  iew  years.  In 
eight  of  these  cases  reduction  b}^  intestinal  distension  was 
attempted.  It  failed  in  all.  In  tAvo  instances  no  effect  Avas 
produced  on  the  tumour,  and  in  the  renuiining  six  the  reduc- 
tion Avas  apparent  only. 

Aniong  these  six  cases  the  folio Aving  may  be  selected 
as  an  example.  The  patient  Avas  a  female  infant,  aged  four 
months,  and  the  invagination  Avas  ileo-csecal.  Air  and  water 
were  injected  tAventy-eight  hours  alter  the  onset  of  the 
symptoms  Avith  apparently  perfect  success.  Nine  hours  later, 
hoAvever,  the  tumour  Avas  felt  as  before.  Injection  was 
employed  again  fourteen  hours  after  the  first  trial,  and  again 
to  all  appearances  Avith  complete  success.  Two  hours  later 
the  intussusception  was  again  felt,  and  injection  Avas  employed 
a  third  time,  and  the  tumour  again  entirely  vanished.  Some 
hours  later  the  child  died,  and  it  was  foimd  that  the  invagi- 

*  lancet,  vol.  i.,  1887,  p.  112.5. 

t  £rit.  Med.  Journ.,  vol.  ii.,  1896,  p.  629. 

X  Clin.  Soc.  Trans.,  1898,  p.  61. 


FOE  a  IB  LE    EN  EM  AT  A.  505 

nation  had  never  been  completely  reduced.     The  last   little 
bit  \vas  too  tight  to  yield,  and  gangrene  was  beginning. 

On  the  subject  of  genuine  recurrence  I  cannot  do  better 
than  quote  from  Mr.  Power's  lectures. 

"  Dr.  F.  H.  Elliott*  has  published  the  details  of  a  case  of  recovery 
from  intussusception  in  a  child,  aged  eight  weeks,  in  whom  recurrence 
took  place  twenty-four  hours  after  the  first  reduction,  five  days  after  the 
second  reduction,  and  thirteen  days  after  the  third  reduction.  Dr. 
Chafiey+  had  a  less  satisfactory  experience,  for  an  intussusception 
recurred  on  five  separate  occasions  until  the  patient— a  boy  aged  three 
years — died  of  exhaustion.  When  recurrence  is  a  very  marked  feature 
in  a  case,  it  is  better  to  open  the  abdomen  at  once  rather  than  to  trust  to 
repeated  irrigation  of  the  bowel,  for  it  appears^  that  reinvagination  can 
positively  be  prevented  by  shortening  the  mesentery  at  the  point  of 
invagination  by  folding  it  upon  itself  in  a  direction  parallel  to  the 
bowel,  and  maintaining  it  in  this  position  by  a  few  catgut  sutures.  Xo 
absolute  rule  can  be  laid  dow^n,  however,  for  a  child  is  now  under  my 
care  who  apparently  has  been  cured  of  intussusception,  though 
irrigation  had  to  be  done  on  five  separate  occasions  before  the  tendency 
to  recurrence  was  overcome. 

"  There  appear  to  be  several  reasons  for  this  tendency  to  recurrence. 
The  first  and  the  least  satisfactory  is  that  the  conditions  which  led  to 
the  original  intussusception  may  persist.  An  intussusception  would 
then  recur  after  any  method  of  treatment,  but  it  is  particularly  likely 
to  do  so  when  the  reduction  has  been  brought  about  by  distension  of 
the  large  intestine.  A  rapid  distension  of  the  colon  followed  by  its 
sudden  emptying  are  exactly  the  conditions  which  lead  to  increased 
peristalsis  of  its  active  and  as  yet  uninjured  walls.  All  methods  of 
treating  intussusception  by  dilatation  of  the  bowel  are  therefore  open  to 
the  objection  that  they  predispose  to  a  fresh  invagination  of  the  con- 
gested, compressed,  and  partially  paralysed  portion  of  intestine  which 
has  just  been  released.  A  second  objection  to  this  method  of  treatment 
lies  in  the  fact  that  the  operator  cannot  see  what  he  is  doing,  and 
that  it  is  necessarily  performed  with  uncertain  guides.  The  reduction 
is  therefore  incomplete  in  some  cases,  for  the  last  part  of  an  intussuscep- 
tion is  the  most  difficult  to  unfold,  and  in  practice  when  the  tumour 
has  disappeared  as  a  result  of  irrigation  the  operator  is  usually  chary  of 
continuing  the  process,  and  he  is  quite  content  to  allow  the  fluid  to 
escape  as  soon  as  possible.  Cases  are  well  known  in  which  such  an 
incomplete  reduction  has  been  found  at  the  necropsy.  Dr.  Goodbart§ 
records  one  where  a  local  oedema  of  the  submucous  tissue,  with  a  slight 
invagination  of  all  the  coats  of  a  ])art  of  the  caecum,  remained  after  an 
intussusception  had  been  reduced  by  inflation.  He  thought  that  the 
invagination  was  sufficient  to  start  a  fresh  intussusception,  though  he 
confesses  that  it  is  more  likely  that  the  swelling  would  have  subsided 
if  the  patient  had  lived  a  longer  time.  Professor  Greig  Smith*"  also 
quotes  a  case  in  which  the  appendix  was  found  unreduced  after  death, 
and  still  invaginated  Avithin  the  c;^cum.  The  ileo-ctecal  valve,  too,  is 
sometimes  a  cause  of  trouble  after  the  reduction  of  an  intussusception 

*  Lancet,  vol.  i.,  1887,  p.  67. 

t  Ibid.,  vol.  ii.,  1887,  p.  17. 

J  Seim ;  Intestinal  Surgery,  p.  9o. 

\  Trans.  Clin.  Soc,  1883,  p.  62. 

%  Abdominal  Surgery,  1896,  vol.  ii.,  p.  678. 


506         TREATMENT    OF    ACUTE    INTUSSUSCEPTION. 

theoretically  because  a  haemorrhage  into  its  substance  may  make  its 
segments  gape,  or  may  so  stiffen  them  as  to  predispose  to  a  fresh 
invagination  of  the  ileum,  practically  because  it  may  be  mistaken  in  its 
inflamed  state  for  the  tumour  of  an  intussusception.  This  mistake  has 
been  made  more  than  once,  and  on  one  occasion*  it  led  tbe_  surgeon 
to  open  the  abdomen  of  a  child  aged  six  months,  in  the  full  belief  that  a 
previous  irrigation  had  failed  to  reduce  the  whole  intussusception." 

Some  surgeons  use — in  tbe  place  of  water — warm  olive  oil. 
Mr,  Clubbe  is  an  advocate  of  this  substitute.  He  introduces 
the  oil  by  means  of  an  ordinary  enema  syringe,  the  patient 
being  at  the  time  under  an  ansesthetic.  He  relates  three 
cases  in  which  injections  of  oil  succeeded  after  the  symptoms 
had  existed  for  forty-eight  hours,  thirty  hours,  and  seven 
hours  respectively,  t 

The  after-treatment  of  a  case  in  which  an  intussaisception 
has  been  reduced  by  eneniata,  irrigation,  or  inflation,  consists 
in  keeping  the  child  at  rest,  observing  a  careful  diet,  and 
giving  for  a  day  or  two  a  little  opium. 

The  patient  must  be  careftdly  watched,  as  a  recurrence 
of  the  intussusception  is  comjnon. 

The  contra-indications  in  this  measure  of  treatment  are 
the  following.  Enemata  and  irrigation  are  useless  in  the 
enteric  form  of  intussusception,  and  are  not  likely  to  succeed 
in  the  ileo-colic  form.  Xo  attempt  should  be  made  to 
reduce  the  invagination  by  distension  of  the  colon  in  very 
acute  cases  or  in  cases  attended  with  much  collapse  or  in 
which  there  is  abundant  haemorrhage,  or  in  which  the 
symptoms  have  existed  over  twelve  hours. 

In  certain  chronic  cases  reduction  has  been  effected  by 
enemata  many  weeks  after  the  onset  of  the  symptoms,  and 
in  cases  which  may  be  called  subacute  injections  have  suc- 
ceeded in  reducing  invaginations  which  have  existed  for 
six  and  nine  days.  X  These  cases  are,  however,  not  material 
to  the  present  matter. 

By  many  surgeons  the  method  of  treatment  now  under 
discussion  is  condemned,  and  this  condemnation  applies  alike 
to  injections  of  water,  oil,  air,  or  gas.  The  arguments  used 
are  these: 

(1)  The  measure  is  ver}'  uncertain,  and  may  fail  abso- 
lutely in  the  most  favourable  type  of  case. 

(2)  It  is  dangerous,  and  a  number  of  instances  are  re- 
corded in  which  the  bowel  has  been  ruptured  or  rent  by  the 
injection. 

*  Lancet,   vol.   ii.,    1892,    p.    380,      Another  example  of   this  misrake    is 
detailed  in  the  Brit.  Med.  Journ.,  vol.  ii.,  1897,  p.  1336,  case  xiv. 
t  Brit.  Med.  Journ.,  November  6,  1897. 
%  Lancet,  vol.  ii.,  1892,  p.  1441,  and  St.  Bart.'s  Hosp.  Reports,  1892,  p.  115. 


FORCIBLE    EiYEMATA.  507 

(3)  It  is  uncouth  and  lacking  in  precision.  The  surgeon 
CAnnot  see  what  he  is  doing. 

(4)  It  involves  a  considerable  waste  of  valuable  time. 
The  child  when  recovering  from  the  anaesthetic  (adminis- 
tered while  the  injection  is  being  given)  may  appear  to  be 
free  from  pain  and  to  have  recovered.  This  appearance  may 
be  encouraged  if  full  doses  of  opium  have  been  given  before 
the  injection,  and  is  promoted  also  by  such  shock  as  may 
be  present,  and  by  the  absence  of  feeding.  The  intussuscep- 
tion may  be  still  in  existence  and  the  prospects  of  an 
operation  very  considerably  damaged. 

(5)  In  many  recorded  cases  there  has  been  a  great  doubt 
as  to  whether  the  intussusception  has  or  has  not  been 
reduced.  Some  swellins-  is  felt  in  or  about  the  bowel  which 
has  caused  this  uncertainty. 

Under  the  inlluence  of  this  doubt  the  abdomen  has  been 
unnecessarily  opened,  on  the  one  hand,  and  the  invagination 
found  to  be  quite  reduced ;  while,  on  the  other  hand,  opera- 
tion has  been  postponed,  the  intussusception  being  still  in 
existence.  The  invagination  may  appear  to  be  quite  reduced, 
and  no  tumour  of  any  kind  may  be  felt  on  careful  examina- 
tion of  the  abdomen,  and  yet  all  the  time  a  part  of  the 
intussusception  may  be  still  not  unfolded. 

(6)  This  method  of  treatment,  even  when  it  succeeds,  is 
very  apt  to  be  associated  with  a  speedy  recurrence  of  the 
intussusception.  There  is  no  doubt  but  that  in  many  ot 
these  cases  of  apparent  temporary  success  the  gut  was  never 
entirely  reduced. 

Those  who  are  in  opposition  to  this  procedure  say  that 
its  only  advantage  lies  "  in  the  slight  parental  opposition 
to  its  employment." 

It  will  be  desirable  to  supplement  these  criticisms  by 
some  statistical  record  of  the  results  of  the  treatment  of 
intussusceptions  by  rectal  injections  of  any  kind. 

Dr.  Wiggin  "^  has  collected  103  recorded  cases  of  intus- 
susception which  were  treated  by  intestinal  distension  or 
laparotomy.  In  seventA^-two  instances  intestinal  distension 
was  practised.  Of  this  number  failure  to  effect  reduction 
occurred  in  fifty-four  instances,  or  75  per  cent. 

It  must  be  remembered  that  in  this  series  cases  of  all 
degrees  of  severity  are  included.  In  thirty-nine  of  the 
seventy-two  cases  treatment  by  intestinal  distension  repre- 
sents the  only  means  employed ;  of  this  number  sixteen 
recovered  (41  per  cent.)  and  twenty- three  died  (a  mortality 
of  59  per  cent.). 

*  A'^cw   York  Med.  Rec.    Jan.   18,   1896. 


508        TREATMENT    OF   ACUTE    INTUSSUSCEPTION. 

In  the  remaining  instances  out  of  the  series  of  seventy- 
two,  the  treatment  of  intestinal  distension  was  followed  by 
laparotomy. 

Mr.  Murray  ^  alludes  to  twelve  cases  treated  by  rectal 
injections,  in  which  a  good  result  followed  in  four  only. 

Mr.  Barker  t  has  collected  twenty- eight  cases  in  which 
injection  was  tried.  In  eleven  of  these  cases  the  tumour 
was  successfully  reduced. 

The  old  records  of  the  treatment  of  intussusception  by 
intestinal  distension  present  a  very  dark  picture.  Fluid 
was  in  not  a  few  cases  pumped  into  the  bowel  until  it 
burst,  no  regard  being  had  as  to  the  amount  introduced 
or  the  force  employed.  Injections  were  now  and  then  made 
while  the  narcotised  child  was  held  in  the  inverted  position. 
The  abdomen  was  often  kneaded  and  pummelled  until  the 
possibly  gangrenous  gut  gave  way,  or  the  child,  while  held  in 
the  inverted  posture,  was  shaken  as  if  it  had  been  a  bottle 
of  medicine. 

If  the  treatment  by  distension,  however,  be  carried  out  Avith 
proper  care  at  the  earliest  possible  moment  and  in  selected 
cases,  it  cannot  be  denied  that  it  is  of  some  service.  The 
contra- indications  for  the  measure  have  been  already  given, 
and  it  will  be  seen  that  they  are  numerous,  and  that  the 
treatment  of  intussusception  by  intestinal  distension  is 
limited  to  but  a  very  few  cases. 

Barker  I  in  reviewing  lifteen  cases  of  acute  intussuscep- 
tion which  had  been  under  his  care,  mentions  that  injection 
was  tried  in  eight  of  these  cases  and  failed  in  all.  "  Out 
of  these  fifteen  cases,  twelve  could  not  possibly  have  been 
reduced  by  injection  at  the  time  they  were  first  seen  by 
me ;  in  two,  because  they  were  of  the  enteric  variety ;  in 
three,  because  they  were  ileo-colic  ;  in  two  because  gangrene 
was  already  present ;  and  in  the  remaining  five,  because 
the  strangulation  and  consequent  oedema  were  too  great  to 
be  overcome  by  pressure  from  below.  It  is  plain,  then, 
that  in  this  series  only  one  in  three  had  the  slightest 
chance  of  being  relieved  by  injection  when  I  saw  them." 

Mr.  Barker  would  limit  the  employment  of  injection  to 
selected  cases  seen  within  a  few  hours  of  the  onset  of  the 
symptoms.  On  this  matter  of  time,  it  is  well  to  point  out 
that  in  the  series  of  cases  collected  by  Dr.  Wiggin,  there 
are  thirty-nine  in  which  the  only  treatment  was  by  intestinal 
distension.     Of  this  number  41  per  cent,  recovered,  and  the 

*  Lancet,  Nov.  18,  1898,  p.  1324. 
t  Clin.  Soc.  Trans.,  1898,  p.  63. 
t  Ibid. 


INSUFFLATION    WITH   AIR.  509 

average  hour,  after  the  onset  of  the  symptoms,  at  which 
the  treatment  was  begun  was  the  twenty- eighth,  the  ex- 
tremes being  five  hours  on  the  one  hand,  and  forty-eight 
hours  on  the  other.  In  Mr.  Barker's  series  of  forty-three 
cases  (see  page  521)  injection  only  was  employed  in  eleven 
cases,  with  nine  recoveries  and  two  deaths.  In  the  cases 
which  recovered,  the  average  hour  at  which  the  injection 
was  employed,  after  the  onset  of  the  attack,  was  the 
fifteenth,  the  extremes  being  two  hours  and  thirty-one 
hours.  In  the  fatal  cases  the  average  hour  was  the  twenty- 
sixth. 

I  have  suggested  that  the  attempt  to  reduce  the  in- 
vagination should  not  be  made  when  the  symptoms  have 
existed  more  than  twelve  hours  (page  506),  and  I  believe  that 
that  limit  will  be  proved  by  experience,  to  err  on  the  side 
of  liberality. 

The  position  with  regard  to  the  very  acute  cases  is  well 
illustrated  by  an  instance  of  ileo-colic  intussusception  re- 
corded by  Mr.  Godlee.  ^  The  patient  was  a  male  infant, 
six  months  old.  The  symptoms  were  very  acute,  and  the 
abdomen  was  opened  six  hours  after  the  onset  of  the 
symptoms.  No  inflation  of  the  bowel  had  been  attempted. 
The  invagination  was  reduced  with  much  difficulty ;  and,  while 
it  was  safe  to  say  that  it  could  not  have  been  reduced  by 
intestinal  distension,  it  was  evidently  a  case  in  which  a 
partial  reduction  might  well  have  led  to  the  impression 
that  the  whole  invao-ination  had  been  overcome. 

Furthermore,  the  rule  should  be  observed  that  m  any 
case  in  which  distension  of  the  bowel  has  been  employed, 
an  immediate  laparotomy  should  follow  in  all  instances  in 
which  the  reduction  has  failed  or  is  reasonably  suspected 
to  have  failed.  There  is  nothing  to  commend  the  practice 
of  repeated  attempts  at  reduction  by  this  method.  The 
treatment  should  be  limited  to  one  attempt. 

5.  Insufflation  with  Air  or  Certain  Gases. — It  has 
been  already  observed  that  distension  of  the  bowel  with 
fluid  is  a  more  potent  measure  in  the  reduction  of  intus- 
susceptions than  is  insufflation  with  air  or  gas.  The 
remarks  which  have  just  been  made  as  to  the  advantages 
and  disadvantages  of  intestinal  distension  with  fluid,  and 
as  to  the  dangers  of  the  method  apply  equally  to 
that  now  under  discussion.  The  indications  and  contra- 
indications for  these  measures  of  treatment  are  the 
same. 

The  air  has  been  introduced  by  means  of  a  common  bellows, 

*  Lancet,  vol.  ii.,   1898,  p.   1262. 


510 


TREATMENT    OF    ACUTE    mTUSSU^CEPTION. 


to  which  an  indiarubber  pipe  and  a  rectal  tube  have  been 
attached."^ 

More  iisuall}'  an  ordinar}"  Higginson's  syringe  has  been 
used.  As  an  example  of  its  employment  may  be  quoted  a  case 
recorded  by  Dr.  Cheadle.f  The  jjatient  was  a  baby,  aged  four- 
teen months,  and  the  symptoms  had  existed  for  six  days.     Air 


>,  air  syringe  ;  b,  shoulder  on  end  of  liandle  c  ;  d,  point  where  air  enters  the  rectuni-tul>e 
K,  hollow  elastic  ring  ;  f,  a  long  narrow  rectum-tube  fir  cases  of  rectal  stricture,  eic. 

was  introduced  into  the  colon  by  means  of  Higginson's  syringe 
while  the  child  was  under  the  influence  of  chloroform.  The 
bowel  was  inflated  until  the  abdomen  was  "  decidedly  tense." 
Three  inflations  were  employed  under  the  same  anaesthetic, 
when  the  mass  was  found  to  be  reduced.  One  drop  of  liquor 
opii  sedativus  was  then  given  every  three  hours,  and  the  child 
made  a  good  recovery.  Dr.  Cheadle,^  in  another  paper, 
alludes  to  three  cases  of  success  after  inflation,  the  symptoms 
having  existed  for  twenty-four  hours,  seven  days,  and  ten  and 
a  half  days  respectively. 

The  best  instrument,  however,  for  the  present  purpose 
is  that  designed  by  Mr.  lAmd,  of  Manchester  (Fig.  117).  It 
consists  of  an  air-syringe  and  a  rectum-tube.  "  The  merit  of 
the  invention,"  writes  Mr.  Lund,  "consists  in  a  particular  mode 
of  securing  an  air-tight  contact  around  the  margin  of  the 
anus,  by  the  use  of  a  hollow  elastic  ring  e  placed  over  the 
tube,  which  is  compressed  and  flattened  against  the  shoulder 
B  on  the  handle  c,  when  firmly  pressed  against  the  part  by  an 
assistant.  This  method  of  preventing  the  return  of  the  air  as  it 
is  pumped  into  the  bowel  is  more  eflective  than  anything  of  the 
nature  of  a  plug  or  tampon  introduced  within  the  rectum, 
even  if  it  be  carefully  adjusted  to  the  size  of  that  cavity,  for 

*  Dr.  Trastour  :  Bull.  g-en.  de  Therap.,  1874,  p.  107. 
t  Lancet,  vol.  i.,  1889.  p.  171. 
X  Ibid.,  vol.  i..  188G,  p.   766. 


IN'SUFFLATION    WITH    CARBON IC    ACID.  511 

the  air  so  injected  is  sure  to  escape  by  the  side  of  the  plug, 
the  anus  and  the  rectum  being  immensely  exjDansible.  .  .  . 
With  the  apparatus,  when  the  hollow  ring  is  compressed,  the 
central  hole  in  it  is  diminished  in  size,  the  skin  around  the 
anus,  to  which  the  indiarubber  clings  with  great  tenacity,  is 
drawn  inwards  towards  the  centre,  and  the  tightness  of  the 
air-joint  thus  formed  can  be  well  sustained."'^ 

The  Use  of  Carbonic  Acid. — Distension  of  the  colon  by 
carbonic  acid  may  be  effected  in  two  ways.  In  the  first 
method  the  gas,  suspended  in  water,  is  deriv^ed  from  an 
ordinary  "  syphon  "  of  seltzer  or  soda-water.  A  tube  is  passed 
up  the  rectum  as  far  as  it  will  go.  To  the  end  of  this  tube  an 
indiarubber  pipe  is  attached  which  is  connected  by  its  other 
extremity  with  the  nozzle  of  a  "  syphon."  The  syphon  should 
be  of  large  size,  capable  of  holding  a  quart.  An  assistant 
presses  the  margins  of  the  anus  against  the  tube,  and,  ever}'- 
thing  being  in  readiness,  the  button  of  the  syphon  is  pressed, 
and  its  contents  pass  into  the  rectuin.t  Here  the  material 
injected  is  a  mixture  of  water  and  of  gas. 

In  the  second  method  the  distension  is  effected  by  in- 
troducing first  a  solution  of  bicarbonate  of  soda,  and 
then  a  solution  of  citric  or  tartaric  acid  into  the  rectum,  so 
that  the  2'as  is  o-enerated  within  the  bowel.  A  lono-  rectal  tube 
is  used,  which  is  connected  by  an  indiarubber  pipe  with  a 
glass  funnel.  The  two  drugs  are  introduced  in  solution,  one 
being  poured  in  after  the  other  has  had  full  time  to  find  its 
way  into  the  intestine.  When  the  two  solutions  have  been  in- 
troduced, a  certain  quantity  of  water  is  rapidly  poured  in ;  the 
escape  of  the  gas  is  prevented  by  forcibly  pressing  the  buttocks 
together  about  the  tube,  escape  also  being  prevented  along 
the  tube  itself  Here  also  a  quantity  of  nuid  is  introduced 
with  the  gas.  Ziemssen,  who  has  written  in  high  praise  of 
this  mode  of  distending  the  bowel,  says  that  for  complete 
dilation  of  the  colon  in  an  adult  twenty  grammes  of  bicar- 
bonate of  soda  are  required  and  fifteen  grammes  of  tartaric 
acid.  He  recommends  that  the  solutions  should  be  intro- 
duced gradual!}',  or  at  least  in  three  parts.  He  points  out 
that  the  ileo-cyecal  valve  remains  firm  even  aojainst  strono;- 
pressure,  but  asserts  that  under  the  influence  of  the  carbonic 
acid  it  may  yield  a  little,  so  as  to  allow  gas  to  reach  the  small 
intestine.]:  Ziemssen  expresses  his  belief  that  this  form  of 
injection  is  more  etficacious  in  the  reduction  of  intussuscep- 
tion than  is  the  more  usual  enema  of  water. 

*   Lancet,  vol.  i.,  1883,  p.  .')8S. 

+  See  Bull.  gen.  de  Therap.,  1887.  p.  22.S  :  Dr.  Gamier. 

t  Archiv  fiir  kiin.  Med.,  bd.  33.  3  and  4:. 


512        TREATMENT    OF   ACUTE    INTUS8USGEPTI0K. 

Williams*  gives  an  account  of  an  invagination  which  was 
reduced  siiccessfuUy  by  means  of  a  carbonic  acid  enema 
employed  after  the  symptoms  had  existed  for  twenty-four 
hours. 

The  Use  of  Hydrogen. — Sennf  has  advised  the  disten- 
sion of  the  bowel  with  hydrogen  gas. 

"Hydrogen  gas  can  be  readily  generated  in  a  large  wide-inouthed 
bottle,  into  which  a  small  handful  of  chips  of  pure  zinc  is  placed.  The 
mouth  of  the  bottle  is  closed  with  a  cork  with  two  perforations,  through 
which  two  glass  tubes  are  inserted,  one  for  the  purpose  of  pouring  in 
water  and  sulphuric  acid,  and  the  other,  which  should  be  bent  nearly 
at  right  angles,  for  leading  away  the  gas.  This  glass  tube  and  a  rubber 
balloon,  with  a  capacity  of  sixteen  litres  of  gas,  are  connected  by  means 
of  a  rubber  tube.  In  from  five  to  ten  minutes  the  requisite  amount  of 
gas  can  be  generated,  and  everything  is  ready  for  the  inflation.  The 
rubber  tube  connecting  the  balloon  with  the  rectal  tip  of  an  ordinary 
syringe  should  be  interrupted  by  a  stopcock,  so  that  the  escape  of  gas 
can  be  prevented  whenever  inflation  is  temporarily  suspended.  The 
return  of  the  gas  along  the  sides  of  the  rectal  tip  can  be  readilj"^ 
prevented  by  an  assistant  pressing  the  anal  margins  firmly  against  it." 

The  inflation  is  carried  out  while  the  patient  is  under  an 
ansesthetic.  Senn  states  that  the  gas  can  be  readily  forced 
beyond  the  ileo-csecal  valve,  and  that  the  method  is  ap- 
plicable to  the  enteric  form  of  intussusception  as  well  as  to 
the  other  varieties. 

So  rapid,  however,  are  the  changes  which  take  place  in 
the  bowel  in  enteric  intussusception  that  it  is  a  question 
whether,  when  once  well  established,  they  could  ever  be 
reduced  by  distension  applied  through  the  rectum.  On  this 
point  BarkerJ  writes  : — 

"From  what  I  have  seen  in  the  living  body  in  five  cases  in  which  I 
have  opened  the  abdomen  for  intussusception  above  the  valve  I  am 
convinced  that  no  amount  of  distension  from  below,  even  if  the  valVe 
could  have  been  passed,  would  have  undone  the  invagination." 

The  pressure  upon  the  rubber  balloon  should  be  uninter- 
rupted, and  should  never  exceed  two  pounds  to  the  square 
inch.  The  inflation  must  be  conducted  very  slowly.  There 
is  no  evidence  to  show  that  this  method  has  any  advantage 
over  the  usual  mode  of  intestinal  distension  by  means  of 
Avater. 

Treatment  of  Intussusception  by  Laparotomy. — Lapar- 
otomy to  be  successful  in  cases  of  intussusception  must  be 
pert'ormed  early.  The  conditions  have  been  detailed  Avhich 
would  encourage  the  use  of  intestinal  distension  (page  501 ). 
If  the  case  be   considered   unfit  for   this   measure — and  the 

*  Lancet,  vol.  i.,  1894,  p.  537. 

t  Intestinal  Surgery,  Chicago,  1889,  p.  244 

I  Clin.  Soc.  Trans.,  1898,  p.  59. 


LAI'Alli)'r().\JV.  513 

majority  of  the  acute  cases  are  iiufit— laparotoiuy  .sli(»ul(l  be 
perforiiicd  without  the  least  deJay.  Or  if  distension  has  been 
employed  and  has  proved  unavaihng,  the  abdomen  should  be 
opened  at  once,  while  the  child  is  still  under  the  anaesthetic 
given  to  allow  of  the  injection  being  administered. 

The  incision  is  most  conveniently  made  in  the  median  line. 
Some  surgeons  advise  that  the  abdomen  be  opened  imme- 
diately over  the  tumour  or  in  the  right  semilunar  line,  but 
except  in  quite  peculiar  circumstances  the  median  incision 
will  be  found  to  be  the  best.  It  is  certainly  the  best  in  all 
cases  in  children.  The  tumour  should  be  exposed  and  should 
be  brought  outside  the  wound.  Reduction  of  the  invagination 
should  then  be  cautiously  attempted.  Considerable  uncer- 
tainty attends  this  part  of  the  operation.  Reduction  has 
betMi  found  to  be  impossible  when  the  operation  has  been 
carried  out  within  twelve  hours  of  the  onset  of  the  symptoms, 
and  to  be  readily  effected  when  the  symptoms  have  existed 
for  several  days.  Experience  of  such  instances  is  exceptional 
.and  it  may  be  said  that  the  earlier  the  operation  the  easier 
is  the  reduction.  In  reducing  the  bowel  the  tumour  should 
be  straightened  so  far  as  is  possible,  and  an  attempt  made  to 
force  back  the  intussusception  by  squeezing  the  sheath  just 
below  the  apex  of  the  tumour.  It  is  of  very  little  use,  in  any 
but  the  most  simple  case,  to  drag  upon  the  entering  bowel. 
In  marked  and  severe  cases,  such  traction  is  distinctly  to  be 
avoided. 

Sometimes  after  the  reduction  has  been  to  all  appear- 
ances effected  a  lump  can  still  be  felt  within  the  gut,  which 
may  give  rise  to  the  impression  that  the  reduction  is  incom- 
plete. Mr.  Pitts  states  that  thickening  about  the  ileo-coecal 
valve  may  form  a  swelling  which  may  readily  be  mistaken 
foi;'  an  incomplete  reduction.  If  any  doul3ts  exist,  the 
bowel  should  be  opened  and  the  parts  within  examined. 
This  incision  into  the  gut  should  then  be  closed  by 
sutures. 

There  would  appear  to  be  no  need  to  attempt  any  fixation 
of  the  bowel  by  suture  of  the  mesentery,  as  described  on 
page  515. 

After  the  reduction  has  been  effected  the  wound  in  the 
abdomen  is  closed. 

If  the  bowel  be  damao'ed,  or  if  doubt  exist  as  to  its 
power  of  speedy  recovery,  a  gauze  drain  may  be  introduced 
into  the  peritoneal  cavity  and  be  carried  down  to  the  injured 
loop. 

The  after-treatment  of  the  case  differs  in  no  particular 
from  that  observed  after  an  abdominal  operation,  save  that  it 


TREATMENT    OF   ACUTE    INTUSSUSCEPTION' 

arable  that  the  patient  shall  be  kept  under  the  influence 
TOT  ojium  for  some  few  days.'^ 

If  the  intiissusceiotion  cannot  he  reduced- — When  this 
complication  presents  itself,  the  following  courses  have  been 
advised  b}^  one  surgeon  or  another : — 

(1)  The  establishment  of  an  artificial  anus  above 
the  unreduced  intussusception  which  is  left  in  the  abdo- 
men. 

(2)  The  establishment  of  a  lateral  anastomosis  between 
the  gut  above  the  obstruction  and  the  gut  below,  the  unre- 
duced intussusception  being  left  in  the  abdomen. 

(3)  Resection  of  the  intussusception  and  the  formation  of 
an  artificial  anus  at  the  place  of  resection. 

(4)  Resection  of  the  intussusception  and  immediate  union 
of  the  divided  ends  of  the  bowel,  followed  by  closure  of  the 
abdominal  wound. 

(5)  Resection  of  the  intussusceptum  alone.  Barker's 
operation. 

Of  these  five  measures,  experience  has  shown  that  the 
last  is  the  best  and  safest. 

The  first  two  methods  are  to  be  condemned  because 
they  leave  the  mtussusception  untouched  and  permit  it  to 
pass  on  into  a  state  of  gangrene.  An  artificial  anus  has 
been  almost  uniforndy  fatal  in  the  treatment  of  intussus- 
ception. 

I  am  not  aware  of  a  single  case  in  which  recovery  has 
followed  the  employment  of  lateral  anastomosis. 

The  objection  to  the  third  measure  is  based  upon  the 
extreme  fatality  which  has  attended  the  formation  of  an 
artificial  anus  in  intussusception.  The  opening  is  usually 
in  the  lesser  bowel  and  the  majority  of  the  patients  are 
infants  or  young  children.  Rydygiert  mentions  one  case 
which  survived  an  artificial  anus,  but  the  almost  universal 
result  of  this  measure  has  been  death. 

The  fourth  measure,  that  of  resection  of  the  whole 
intussusception  with  immediate  union  of  the  divided  ends 
of  the  bowel,  has  great  attractions,  and  is  theoretically  perfect, 
but  at  present  it  has  been  attended  with  a  fearful  mortality. 
In  Braun's  series  of  cases  there  are  twelve  examples  of 
resection  without  a  single  recovery.  In  Wiggin's  list  of 
operations  for  intussusception  there  are  several  cases,  but 
♦^hey  all  ended  in  death.      In  Barker's  series  of  forty-three 

*  Examples  of  this  type  of  operation  are  afforded  by  cases  in  tlie  Brit. 
Med.  Journ..,  vol.  ii.,  1896,  p.  1113  (Dr.  Eenton) ;  and  the  Lancet,  vol.  i.,  1897, 
p.  1602  {:\Ir.  Pitts). 

t  Verhand.  der  deutsch.  Gesells.  f.  Chirurgie,  1895. 


LAPAROTOMY. 


5i: 


cases  of  intussusception  there  are  four  instances  of  resection, 
all  of  which  were  fatal.  "^ 

On  the  other  hand  there  are  examples  of  successful 
excision  of  an  intussusception,  but  the  number  is  still  small. 

Koch  erf  has  resected  the  entire  invagination  in  five 
cases.  All  the  patients  recovered.  Rydygier  has  collected 
twelve  examples  of  this  measure  with  three  recoveries. 
Other  isolated  cases  have  been  published.  One  published 
by  Mr.  ClubbeJ  is  of  interest  be- 
cause the  patient  was  only  eleven 
months  old.  The  intussusception 
was  of  the  ileo-colic  form,  and  the 
operation  was  performed  on  the 
ninth  day.  The  union  was  effected 
by  a  double  row  of  catgut  sutures. 
In  all,  four  inches  of  the  ileum 
were  removed.  A  gauze  drain  was 
introduced,  and  the  child  was  re- 
ported to  be  well  in  fourteen  days, 
in  spite  of  a  desperate  attack  of 
gastro-enteritis. 

The  fifth  measure,  that 
devised  by  Mr.  Barker,^  appears 
to  offer  the  best  prospects  of 
recovery  and  has  so  far  been 
attended  with  the  best  results. 

The  principle  of  the  operation 
is  the  excision  of  the  intussus- 
ceptum  through  a  cut  made  in 
the  intussuscipiens. 

At  the  neck  of  the  invagination,  i.e.  at  the  point  where 
the  sheath  receives  the  entering  layer,  the  two  portions  of 
bowel  are  united  by  means  of  a  continuous  suture  of  fine 
silk.  (Fig.  118,  A.)  This  suture  takes  up  the  serous  and 
muscular  coats  and  is  carried  on  to  the  mesentery.  If  there 
be  any  sign  of  gangrene  about  the  neck,  more  gut  is  in- 
vaginated  before  the  suture  is  inserted.  A  longitudinal 
incision  is  then  made  through  all  the  coats  of  the  intussus- 
cipiens along  its  Iree  margin  or  convex  side.  The  intussus- 
ceptum  is  thus  exposed,  is  drawn  out  through  the  incision 
made  in  the  sheath,  and  is  entirely  divided  as  near  as  possible 
to  its  upper  end.     This  involves,  of  course,  the   division  of 


Fig.  118. -Barker's  Operation  fcr 
Irreducible  Intussusception. 

A,  continuous  suture  at  npck  of  tie 
intussusception,  b,  suture  of  tl.e 
divided  layers  otbowel  after  excision 
of  the  intussusceptiini. 

(From  Ayinals  of  Surgery.) 


*  These  various  series  of  cases  are  alluded  to  in  the  next  section,  p.  521. 
t  £rit.  Med.  Journ.,  Oct.  29,  1898. 
I  Ibid.,  Nov.  6,  1897.  p.  1336. 
§  La/u-et,  Jan.  9,  1892,  p.  79. 


516  TEEAnffJXT  OF  OT^^TRJJOTIQX  BY  G.ILL   ST0XE>1. 

.two  layers  or  riiig-s  of  bowel.  Stout  silk  ligatures  are  passed 
through  all  the  walls  of  the  stump,  and  are  tightly  tied  so  as 
to  keep  the  serous  surfaces  in  contact  and  to  control  all 
bleeding  from  the  vessels  entering  at  the  mesenteric  attach- 
ment. (Fig.  118,  B.)  The  earlier  sutures  are  introduced  before 
the  section  of  the  bowel  is  complete.  Indeed,  as  soon  as 
a  convenient  portion  of  the  intussusceptum  has  been  divided, 
the  two  cut  layers  of  gut,  which  are  thereby  exposed,  are 
secured  by  silk  sutures.  From  four  to  six  sutures  Avill 
suffice  for  this  part  of  the  operation.  The  last  of  the  sutures 
includes  the  stump  of  the  mesentery,  which  is  not  divided 
until  the  suture  has  been  tied.  Care  should  be  taken  to 
see  that  the  lumen  of  the  intussusceptum  is  clear. 

The  stump  is  cleaned  and  dried,  and  dusted  with  iodoform. 
It  is  then  allowed  to  drop  back  through  the  incision  into  the 
lumen  of  the  intussuscipiens.  The  longitudinal  incision  in  the 
latter  is  now  closed  and  the  abdominal  wound  adjusted  by 
sutures.  If  there  be  an}^  suspicion  as  to  the  state  of  the  gut 
at  the  site  of  the  operation  a  gauze  drain  may  be  introduced. 
If  the  intussusceptum  cannot  be  drawn  out  through  the  cut 
in  the  sheath. it  must  be  divided  in  .sifa,  and  the  suturing  oi 
the  stump  proceeded  with.  In  a  case  of  Leszczynski's  the 
amputated  intussusceptum  could  not  be  extracted  and  it  was 
left  to  be  passed  by  the  stools. 

Many  modifications  of  this  operation  have  been  devised-, 
but  the}'  are  of  little  moment  and  appear  to  offer  no  material 
advantages  over  the  original  operation. 

//  the  intussusception,  inclvAing  the  intussuscipiens,  he 
gangrenous. — In  the  face  of  this  deplorable  evidence  of  a  too 
long  delayed  treatment  there  is  nothing  to  be  done  but  to 
excise  the  whole  mass.  If  it  be  possible  this  excision  should 
be  followed  by  immediate  union  of  the  divided  ends  of  the 
bowel.  In  the  case  of  adults  some  hope  may  attend  this 
measure,  and  in  such  patients  a  temporary  artificial  anus 
may  be  entertained  in  the  most  extreme  cases. 

"  When  gangrene  is  present  in  young  children,"  writes  Mr.  Pitts,* 
"  the  condition  is  almost  hopeless.  Complete  resect'on  and  end-to-end 
union,  whether  by  IMurphy's  button  or  suture,  so  far  has  been  practi- 
cally without  success.  Perhaps  rapid  resection,  with  lateral  implanta-. 
tion  of  the  smaU  bowel  into  a  healthy  portion  of  the  colon,  and  bringing 
the  cut  end  of  the  large  bowel  to  the  surface  as  a  temporary  vent  for 
the  escape  of  flatus,  would  be  the  quickest  and  safest  method  to  adopt. 
Safely,  hov/ever,  as  infants  stand  a  short  operation,  a  prolonged  one 
under  such  circumstances  seems  almost  beyond  their  power." 

1).  Acute  Obstruction  of  the  Bowel  by  Foreign 
Bodies,  Gall  Stones,  etc. — In  these  cases,  as  soon  as  the 

*  lancet,  June  12,  LS97,  p.  1002. 


LAPAROTOMY.  517 

symptoms  of  obstruction  are  |)ronounced  laparotomy  should 
be  performed.  If  the  obstruction  be  high  up  in  the  jejunum 
it  is  especially  desirable  that  the  stomach  be  well  washed 
cut  beforehand.  When  any  part  of  the  small  intestine  is 
involved  this  preliminary  measure  is  desirable.  When  the 
upper  jejunum  is  concerned,  it  is  necessar}"  to  .empty  the 
bowel  as  much  as  possible,  as  in  a  neglected  case  a  tem- 
porary artificial  opening  in  that  position  can  hardly  be 
entertained. 

It  must  be  borne  in  mind  that  smooth  foreign  bodies  are 
often  passed  even  when  obstruction  symptoms  have  been 
induced,  and  that  in  cases  of  impacted  gall  stone  52  per  cent, 
of  the  patients  have  recovered  Avithout  operation. 

The  incision  should  be  made  in  the  median  line. 

In  a  few  instances  in  which  the  position  of  the  foreign 
body  is  particular]}^  marked  an  incision  directly  over  the 
obstructing  substance  may  be  preferable. 

A  gall  stone  impacted  in  the  lower  ileum  has  been  squeezed 
through  the  ileo-ctecal  valve  by  the  surgeon,  the  parts  having 
been  exposed  by  laparotomy. 

Mr.  Clutton"^  reports  such  a  case.  The  stone  was  in  the 
ileum  eight  inches  from  the  ciecum.  It  was  left  in  the  colon, 
and  was  passed  per  anum  five  days  after  the  operation.  It 
measured  one  inch  and  a  quarter  by  one  inch.  The  patient 
did  well. 

In  most  instances  the  foreign  body  must  be  cut  out.  The 
bowel  is  opened  just  above  the  site  of  the  obstacle  by  a 
longitudinal  incision  on  the  border  of  the  gut  most  remote 
from  the  mesentery.  It  is  better  to  divide  the  more  healthy 
bowel  above  the  obstruction  than  that  part  of  the  gut  wall 
which  is  actually  comjaressed  by  the  foreign  substance.  There 
is  no  object  in  breaking  up  a  gall  stone  preparatory  to 
removing  it,  and  there  is  little  to  connnend  the  practice  of 
breaking  up  the  stone  by  needling  it  through  the  bowel  wall, 
and  allowing  the  fragments  to  be  passed  spontaneously.  The 
latter  procedure  may  well  do  more  harm  than  good. 

After  the  substance  has  been  removed  it  is  de.sirable  that 
the  bowel  above  the  obstruction  should  be  allowed  to  empty 
itself  so  far  as  is  possible.  The  state  of  the  gut  at  the  site  of 
the  obstruction  must  be  inquired  into.  If  it  be  viable  the 
incision  in  the  gut  is  closed  by  a  double  row  of  sutures,  a 
continuous  suture  of  the  mucous  niembrane  and  Lembert's 
sutures  for  the  two  outer  coats. 

Should  the  gut  be  hopelessly  damaged  a  temporary  artifi- 
cial anus  may  be  demanded,  or  the  damaged  part  may  be 

*  Trans.  Clin.  8oc.,  1888,  p.  99. 


518     TREATMENT  OF  OBSTRUCTION'  BY  GALL  STONES. 

excised  and  the  bowel  either  at  once  united  or  a  temporary 
opening  established. 

If  there  be  great  distension  of  the  bowel  the  latter  course 
is  to  be  advised.  Indeed,  in  any  neglected  case  with  great 
distension  of  the  small  intestine  and  marked  stercoraceous 
vomiting,  it  is  better  that  a  temporary  enterostomy  should 
be  carried  out. 

The  surgeon  should  be  prepared  to  encounter  adhesions 
and  other  evidences  of  local  peritonitis. 

The  foreign  body  may  have  caused  a  penetrating  ulcer 
of  the  bowel,  or  there  may  be  a  localised  abscess  just  outside 
the  gut  and  into  such  an  abscess  the  foreign  body  may  have 
escaped. 

The  abscess,  when  it  exists,  must  be  opened  through  the 
skin  by  the  most  direct  route  and  to  eftect  this  a  second 
incision  in  the  abdominal  wall  will  probably  be  required. 
When  the  foreign  body  has  been  removed  the  abscess  cavity 
is  drained  with  gauze. 

In  these  cases  attended  with  suppuration  the  less  done 
the  better. 

It  is  needless  to  say  that  nearly  all  the  operations  in 
this  section  have  concerned  the  small  intestine. 

Korte,  '^  however,  reports  a  case  of  acute  obstruction  due 
to  the  impaction  of  a  gall  stone  in  the  colon.  The  patient 
was  a  woman  aged  seventy-two ;  the  gut  Avas  opened  and  the 
stone  removed.     The  patient  died. 

Numerous  examples  of  the  removal  of  impacted  gall  stones 
have  been  reported  in  recent  }'ears. 

Maylardt  has  tabulated  ten  successful  cases  of  this 
operation, 

Khalopoff  :j:  reports  a  case  of  the  successful  removal  of 
two  enteroliths  from  the  colon  by  colotomy. 

*  Berlin,  klin.  Wochens.,  1892,  p.  690. 

t  Surgery  of  the  Alimentary  Canal,  Lond.,  1896,  p.  408. 

J  Annual  of  the  Universal  Med.  Sci.,  1888,  toI.  xxix.,  p.  131. 


519 


CHAPTER    IV. 

THE    PROGNOSIS    AFTER    OPERATION    FOR    ACUTE 
INTESTINAL    OBSTRUCTION. 

It  is  difiicult  to  obtain  reliable  statistics  which  will  display 
the  real  mortality  after  operations  for  acute  obstruction.  A 
collection  of  recorded  cases  is  open  to  the  objection  that  there 
is  a  great  tendency  to  publish  all  the  cases  which  succeed  and 
a  natural  disinchnation  to  place  on  record  those  which  fail. 

It  thus  happens  that  a  collection  of  recorded  cases  selected 
from  various  Transactions  and  journals  is  apt  to  represent 
the  operation  as  more  successful  than  it  really  is. 

On  the  other  hand,  the  enumeration  of  cases  collected 
from  one  or  more  hospitals  will  hardly  give  a  fair  picture 
because  it  will  include  a  number  of  quite  desperate  cases 
which  came  under  notice  too  late,,  and  will  give  the  impres- 
sion that  the  risk  of  the  operation  is  greater  than  it  really  is. 

Taking  all  things  into  consideration  I  should  place  the 
mortality  after  operations  for  acute  intestinal  obstruction  at 
about  50  per  cent.  The  death-rate  is  becoming  every  year 
less  heavy,  and  when  the  absolute  necessity  for  operation  at 
the  earliest  possible  moment  becomes  more  generally  recog- 
nised there  is  no  doubt  but  that  the  mortality  after  the 
operation  will  gradually  diminish. 

Curtis  *  collected  328  cases  of  acute  obstruction  operated 
upon  since  1873,  with  a  mortality  of  689  per  cent.  In  over 
one  hundred  of  these  cases  the  patient  was  practically 
moribund  at  the  time  of  the  operation.  In  forty-live  of  the 
examples  there  was  excision  of  the  bowel  and  suture,  with 
a  death-rate  of  86"6  per  cent.  In  190  cases  in  which  the 
operation  consisted  simply  in  relieving  the  constriction  the 
mortality  was  57  per  cent. 

*  Annuls  of  yiirgcry.  May,  1888. 


520 


ACUTE    INTESTINAL    OBSTBUCTION. 


Scbramm*  has  published  a  collection  of  193  operations 
for  acute  obstruction,  with  a  death-rate  of  6 4  2  per  cent. 

Holmes  t  gives  an  analysis  of  all  the  operations  for  acute 
obstruction  performed  at  St.  George's  Hospital  between  the 
years  1888  and  1894  (inclusive),  with  this  result: — 


Intussusception 
Volvulus 
Kinking 
Bands    . 


Total  cases.     Death.     Recovery. 


1 
11 


20 


15 


ObalinskiJ  furnishes  an  account  of  sixty-six  operations 
for  acute  obstruction,  performed  by  himself,  with  the  fol- 
lowing good  results : — 

Total  cases.     Death.     Kecovery. 
Intussusception 


Volvulus  of  sigmoid  Hexure 
Volvulus  of  Ileum 
Kinking 
Bands    . 
Internal  Hernia    . 


19 

19 

4 

11 

fi 


10 

9 

14 

5 

1 

3 

6 

h 

3 

3 

66 


41 


Kocher,§  in  like  manner,  alhides  to  the  cases  of  acute 
obstruction  upon  which  he  has  himself  operated.  The  total 
number  is  twenty-seven : — 

Total  cases. 
Intussusception    ...       6 
Volvulus       ....       6 
Bands 15 

27 


Death. 
1 
5 

7 


Recovery. 
5 
1 


13 


14 


In  the  five  cases  of  intussusception  which  recovered  the  whole 
invagination  was  excised. 

Naumynll  has  collected  228  cases  of  operation  for  acute 
obstruction,  with  116  recoveries,  i.e.  51  per  cent.  In  twenty- 
four  of  the  cases  the  patient  was  operated  upon  within  forty- 
eight  hours  of  the  onset  of  the  attack.  Of  these  eighteen 
Avere  cured,  making  the  proportion  of  recoveries  75  per  cent. 
Thirty-five  cases  were  operated  upon  on  the  third  day,  with 
twelve  recoveries,  the  recoveries  being  thus  reduced  by  delay 
to  34  per  cent.  Operations  after  the  third  day  yield  recoveries 
in  from  30  to  45  per  cent,  of  the  cases. 

*  l-Hngenljeck's  Archiv,  Bd.  xxx.,  Helt  4. 

t  Brit.  Mvd.  Jimrn.,  July  20,  1895,  p.  125. 

X  Lang-enbeck'ij  Archiv,  1894. 

k  Brit.  Med.  Joiirn.,  Oct.  29,  1898. 

(I  Mitteil.  aus  den  Grenzgeb.  der  Med.  und  Chir.,  Bd.  I.,  S.  98. 


PUOGNOSrH    AFTFAt    Ol'KIlATiON.  621 

The  best  results  in  the  operations  for  acute  obstruction 
have  followed  those  for  the  removal  of  foreign  bodies  and 
gall  stones  ;  then  come  the  operations  for  intussusception,  and 
lastly  those  for  volvulus  and  strangulation  by  bands.  Nauniyn 
gives  twenty-three  operations  for  impacted  gall  stones  with 
sixteen  deaths,  a  mortality  of  70  per  cent.  Most  of  the  cases 
had  been  dealt  with  too  late. 

Eve  collected  eighteen  recorded  cases  of  this  operation 
which  had  taken  place  between  the  years  1881)  and  1895.  01 
these  nine  had  died,  a  mortality  of  50  per  cent. 

The  statistics  in  connection  with  intussusception  are  over- 
whelming. 

Dr.  Wiggin"^  has  collected  103  recorded  cases  of  operation 
for  intussusception.  In  thirty-nine  the  treatment  was  by 
intestinal  distension  only,  with  sixteen  recoveries,  a  propor- 
tion of  41  per  cent.  In  the  remaining  sixty-four  a  laparotomy 
was  performed,  with  twenty-one  recoveries,  showing  the  pro- 
portion of  recoveries  as  328  per  cent.,  and  the  mortality  at 
67"2  per  cent.  Dr.  Wiggin  points  out  that  if  only  the  operations 
are  considered  which  have  taken  place  since  1889,  and  among 
that  number  only  those  which  were  completed,  the  mortality 
sinks  to  only  222  per  cent.  He  believes  that  that  mortality 
"  is  a  fair  estimate  of  the  risk  to-day  of  abdominal  section 
performed  upon  a  young  infant  for  the  relief  of  intussusception, 
if  performed  within  the  first  forty-eight  hours  of  the  onset." 

Rydygiert  deals  Avith  thirty-six  cases  of  operation  for 
intussusception.  In  twenty- four  of  these  the  exposed  in- 
vagination was  reduced,  with  sixteen  deaths  and  eight 
recoveries.  In  the  remaining  twelve  the  gut  was  resected, 
with  nine  deaths  and  three  recoveries, 

Mr.  ClubbeJ  reports  nineteen  cases  of  laparotomy  for 
intussusception,  all  in  his  own  practice.  Of  this  number  nine 
recovered  and  ten  died. 

A  very  valuable  series  of  cases  has  been  published  by 
Mr.  Barker.|  It  includes  all  the  cases  of  acute  intussusception 
treated  at  University  College  Hospital  from  the  beginning  of  the 
3'ear  1877  to  the  end  of  1897.    The  total  number  is  forty-three. 

Treated  by  injection  only 
Laparotomy  after  injection 
Laparotomy  without  injection 
Manipulation  under  cliloroforrn 

*  New  York  Med.  Itecmil.  Jmi.  18,  ISIh;. 

t  Vra-han<ll.  rlor  dcutsch.  CJdsoUs.  fiir  Chir.,  18U5. 

+  Brif.  Mnl.  Joiinl.^  Nov.  (i,  1S'J7. 

{  Clin.  Soc.  Tniiis.,  18t)8.,  p.  07. 


Total  I'ascs. 

Deaths. 

Eecoveries. 

11 

'■I 

9 

](i 

8 

8 

)n       1.5 

8 

7 

irrn       1 

— 

1 

4;i 

18 

25 

522  ACUTE    INTESTINAL    OBSTRUCTION. 

The  average  time  after  the  onset  of  the  attack  at  which  treai- 
iiient  Avas  commenced,  was  fifteen  and  a  half  hours  in  the 
cases  of  recovery  after  injection,  and  twenty-six  hours  in 
the  cases  of  death  after  injection. 

In  the  cases  treated  by  laparotomy  it  is  equally  evident 
that  success  is  in  the  main  dependent  upon  early  operation. 

Maylard  has  tabulated  twenty-five  examples  of  successful 
operation  for  intussusception. 

Reference  has  been  made  already  to  the  result  of  operation 
in  cases  of  volvulus  and  of  strangulation  by  bands. 

Nothnagel  has  collected  thirty  instances  of  volvulus 
treated  by  abdominal  section.  Of  this  number  nineteen  died 
and  eleven  recovered. 


523 


CHAPTER    Y. 

THE    TREATMENT    OF    CHRONIC   INTESTINAL 
OBSTRUCTION. 

A.  Stenosis  OF  the  Small  Intestine. — Under  this  heading 
are  inckided  a  great  many  pathological  conditions  which  are 
all  marked  by  a  partial  mechanical  occlusion  of  the  lumen  ot 
the  bowel  associated  with  the  symptoms  of  chronic  obstruction. 

The  conditions  are  the  following  :  1.  Stricture.  2.  Bend- 
ing of  adherent  intestine.  3.  Adhesion  of  a  coil  in  the 
form  of  a  loop.  4.  Matting  of  adjacent  coils  by  many 
adhesions.  5.  Direct  compression  of  the  gut  by  contracting 
adhesions.  6.  Obstruction  from  shrinking  of  the  mesentery. 
7.  Some  forms  of  internal  hernia.  8.  Obstruction  by  neoplasms. 
9.  Some  cases  of  obstruction  by  gall  stones  and  foreign  sub- 
stances.    10.  Pressure  of  a  tumour  outside  the  gut. 

Feeding". — The  feeding  of  the  patient  is  a  matter  of 
extreme  importance  throughout  the  whole  progress  of  the 
case  and  demands  early  attention. 

The  lumen  of  the  intestine  is  only  partially  occluded. 
Matters  can  pass  readily  through  it  so  long  as  they  are  fluid,  or 
at  least  of  quite  soft  consistence  ;  but  any  large  solid  particles 
passing  along  the  bowel  will  certainly,  if  of  sufficient  magni- 
tude, plug  the  stenosed  part  and  produce  severe  symptoms. 
This  circumstance  is  repeatedly  illustrated  in  the  clinical 
history  of  stricture  of  the  intestine.  Indeed,  the  earlier 
symptoms  of  stenosis  of  the  small  intestine  depend  upon  an 
occasional  entire  occlusion  of  the  tube,  and  this  occlusion  is, 
in  the  majority  of  cases,  due,  directly  or  indirectly,  to  the 
presence  of  masses  of  undigested  food.  The  earlier  tniat- 
ment  of  stricture  of  the  small  intestine  resolves  itself  almost 
solely  into  a  question  of  diet.  So  long  as  the  patient 
exercises  extreme  care  in  the  selection  of  his  food,  so  long 
will  he  remain  free  from  severe  trouble  until  such  time  as 


524       TREATMEST    OF    STENOSIS    OF   SMALL    GUT. 

the  condition  of  the  stricture  will  not  permit  the  free  passage 
of  even  well-digested  matters. 

In  the  management  of  the  case,  therefore,  the  utmost  care 
must  be  paid  to  the  digestion.  Food  .should  be  given  a  httle 
more  frequently  than  usual  in  order  to  avoid  a  "  hearty  meal." 
The  patient  must  rest  after  each  meal,  and  the  process  of 
digestion  may  be  aided  by  the  use  of  artificial  digestives. 

The  food  must  be  such  as  the  patient  can  most  easily 
dispose  of,  and  such  as  will  leave 'the  minimum  of  debris  in 
the  bowel 

As  the  stenosed  part  becomes  narrower  and  narrower  the 
pain  attending  this  form  of  obstruction  is  no  longer  occasional 
and  due  to  the  accidental  blocking  of  the  gut  by  a  large  mass 
of  undigested  food,  but  it  a23pears  more  or  less  constantly  after 
everything  that  is  taken. 

The  patient  at  the  commencement  of  the  trouble  has 
only  to  avoid  distinctly  indigestible  articles  of  food  such  as 
nuts,  pineapple,  tough  meat,  etc.  Later  he  has  to  be  most 
careful  in  the  selection  of  all  the  solid  food  he  takes.  Meat 
gives  pain  and  is  discontinued,  and  the  patient  falls  back 
upon  hsh  and  chicken  which  has  finally  to  be  minced  in 
order  to  pass  the  stricture  with  the  minimum  of  discomfort. 
Sooner  or  later,  if  no  operation  be  performed,  the  diet  becomes 
Avholly  fluid  and  consists  of  soups,  beef-tea,  meat  extracts, 
jellies'^  I'aw  eggs,  peptonised  milk,  koumiss,  Benger's  food, 
and  the  various  preparations  of  "infant's  food."  The  stages 
through  which  the  feeding  passes  are  very  like  those  observed 
in  dealing  with  a  progressive  stricture  of  the  oesophagus. 

With  the  utmost  care  in  the  feeding  it  is  surprising  how 
long  a  condition  of  freedom  from  actual  distress  can  be  main- 
tained in  these  cases. 

In  due  course,  however,  if  the  patient  be  left  still  un- 
relieved by  operation,  all  food  gives  distress.  The  digestion 
is  disturbed  by  opiates  and  possibly  by  frequent  aperients; 
Vomiting  becomes  a  prominent  symptom.  The  patient 
Avastes  and  becomes  markedly  enfeebled  from  want  of 
food. 

It  now  becomes  desirable  to  supplement  the  feeding  by 
the  mouth  by  rectal  feeding. 

Before  the  first  nutrient  enema  is  given  the  rectum 
should  be  washed  out  Avith  warm  water. 

The  fluid  is  introduced  through  a  rectal  tube  of  good 
length,  connected  by  means  of  an  indiarubber  pipe  with  a 
lunnel.  The  patient  should  lie  upon  the  left  side,  with  the 
buttocks  well  raised.  The  elevation  of  the  finmel  above  the 
body  shoidd  be  about  two  feet. 


FEEDING.  525 

The  amount,  of  the  enoiiia  should  be  from  two  to  three 
ounces,  and  its  temperature  that  of  the  body. 

An  enema  can  be  given  every  four  hours,  and  at  least 
once  in  two  days  the  rectum  should  be  well  washed  out 
with  warm  water  to  which  a  little  salt  has  been  added. 

The  material  of  the  nutrient  enema  is  capable  of  almost 
unlimited  variation,  since  the  ingenuity  of  the  physician  has 
been  for  years  past  employed  upon  inventions  and  improve- 
ments in  this  direction. 

Preparations  of  fresh  ox-blood  have  been  used  by  some, 
while  others  have  advocated  "  emulsions  of  meat "  made  up 
with  finely-divided  pancreas  or  with  an  extract  of  the  fresh 
pancreas,  and  preparations  of  fresh  meat  artificially  digested 
by  hydrochloric  acid  and  pepsin. 

The  more  commonly  employed  enemata  consist  of  pep- 
tonised  milk  or  peptonised  beef-tea,  of  various  "  peptonoids," 
and  of  specially  prepared  suppositories  of  milk,  beef,  etc. 

If  a  stimulant  be  needed,  alcohol  can  be  added  to  the 
injection. 

As  I  have  said  elsewhere  (page  464),  the  value  of  nutrient 
enemata  has  probably  been  somewhat  exaggerated.  Water 
and  substances  in  actual  solution  are  readily  absorbed  by 
the  rectum,  but  the  power  of  the  bowel  to  deal  with  many 
of  the  substances  introduced  into  its  cavity  is  very  doubtful. 

An  individual — and  notably  an  adult — who  lies  motionless 
in  bed,  who  is  kept  warm,  and  who  is  well  supplied  with 
water,  can  maintain  life  for  a  considerable  period,  and  the 
value  of  the  nutrient  enema  is  not  entirely  separated  from 
this  wonderful  power  of  endurance  in  the  human  body. 

My  impression  is  that  nothing  is  absorbed  by  the  rectmn 
that  is  not  in  absolute  solution.  The  solid  material  of  the 
"  emulsion "  and  the  solid  particles  which  are  merely  held 
in  suspension  in  many  ingenious  preparations  probably 
remain  in  the  rectum  after  the  fluid  of  the  injection  has 
been  absorbed. 

In  a  case  of  stenosis  of  the  small  intestine  the  commence- 
ment of  rectal  feeding  may  generally  be  regarded  as  the 
beginning  of  the  end,  and  it  is  a  question  as  to  Avhether 
a  patient  should  have  been  allowed  to  reach  that  stage 
without  an  abdominal  operation. 

Opium. — There  is  a  good  deal  of  pain  in  advanced  cases 
of  stenosis  of  the  small  intestine.  It  is  due  to  excessive 
peristaltic  action,  and  represents  the  struggle  of  the  hypers 
trophied  gut  to  force  material  through  the  narrow  strait  in 
its  lumen. 

Coils   of   hypertrophied   intestine   in   movement    will   be 


52fi       TREATMENT    OF    STEXOSTS    OF   SMALL    GUT. 

visible  through  the  attenuated   parietes,  and  accompanying 
such  movements  there  is  pain. 

Attacks  of  severer  pain  also  occur  which  are  due  to  the 
actual  temporary  blocking  of  the  narrowed  bowel. 

The  pain,  whatever  its  cause,  can  only  be  stayed  by  opium, 
and  yet  every  grain  of  opium  given  adds  to  the  patient's 
trouble.  Reduction  in  the  substance  and  solidity  of  the  food, 
or  the  cessation  of  feeding  by  the  mouth,  will,  of  course, 
modify  the  pain  considerably,  but  it  will  not  cause  peristaltic 
movement  to  cease  entirel}^,  and  peristalsis  in  these  cases 
means  pain. 

The  most  hopeless  course  to  pursue  is  to  allow  the  patient 
to  eat  what  he  likes  and  then  to'  allay  the  pain  caused  by 
such  indiscretion  by  the  use  of  opium.  Fortunately,  a  time 
comes  when  unsuitable  food  is  usually  vomited. 

Opium  stills  the  movement  of  the  bowel  throughout  its 
Avhole  course,  and  thus  it  encourages  an  accumulation  in  the 
intestine  above  the  obstruction  on  the  one  hand,  and  dis- 
courages the  emptying  of  the  bowel  below  the  obstruction 
on  the  other. 

In  the  management  of  a  case  of  stenosis  of  the  small 
intestine  an  increase  in  the  amount  of  pain  is  an  indication  uO 
diminish  the  quantity  of  food  taken  by  the  mouth,  and  not 
to  increase  the  amount  of  opium  given. 

Food  excites  peristalsis,  and  peristalsis  in  these  cases 
represents  pain.  The  relief  of  the  pain  is  best  sought  for  in 
the  removal  of  its  cause. 

In  every  case,  however,  opium  cannot  be  long  withheld, 
and  when  it  is  given  the  rule  must  be  observed  to  give  it  in 
the  smallest  possible  quantities  sufficient  to  ensure  ease. 

AVithout  this  narcotic  the  patient  becomes  soon  worn  out. 
The  pain  worries  him  all  day  and  keeps  him  awake  and 
restless  at  night. 

No  ordinary  sedative  will  suffice.  Belladonna  is  of  little 
avail  and  is  not  to  be  recommended.  After  many  experi- 
ments in  this  direction  have  been  tried  the  surgeon  Avill  find 
that  it  must  be  opium  or  nothing.  The  drug  is  always  best 
given  as  a  hypodermic  injection  of  morphia. 

Aperients. — Having  disposed  of  the  questions  as  to  the 
feeding  of  the  patient  and  the  relief  of  his  pain,  another 
prominent  matter  relates  to  the  evacuation  of  tho  bowels. 
These  cases  are  generally  associated  with  constipation. 
Aperients  given  by  the  mouth  cannot  be  long  tolerated. 
1'hey  induce  violent  peristalsis  and  cause  great  pain.  Indeed, 
I  have  seen  a  patient  collapsed  from  pain  following  a  brisk 
purgative  given  in  a  case  of  stricture  of  the  bowel.     In  the 


ENTEROPLASTY.  527 

early  stages  of  the  case  aperients  can  be  tolerated,  and  then 
it  will  probably  be  found  that  salines  are  of  the  most  service. 
The  drug  employed  should  be  frequently  changed,  and  the 
occasional  use  of  castor  oil  or  of  calomel  is  advantageous. 

In  time,  however,  the  main  means  of  evacuatinsr  the 
bowels  must  be  by  enemata,  and  here  also  it  is  of  benefit 
frequently  to  alter  the  composition  of  the  injection. 

In  stenosis  of  the  small  intestine  nothing  is  to  be  gained 
by  the  employment  of  massage  or  by  the  use  of  electricity. 
The  narrowing  of  the  bowel  must  be  quite  considerable  before 
symptoms  can  be  produced,  and  the  measures  employed  do 
no  more  than  excite  peristaltic  movements,  and  such  move- 
ments involve  pain. 

Treatment  by  Operation. — When  once  the  diagnosis  is 
made  in  a  case  of  stenosis  of  the  bowel  the  sooner  the  abdo- 
men is  opened  the  better.  There  is,  of  course,  no  urgenc}^ 
but  it  has  to  be  realised  that  the  condition  cannot  be  remedied 
by  medical  measures  and  that,  although  life  may  be  extended 
for  months  b}^  means  of  careful  treatment,  the  patient 
becomes  gradually  weaker  and  less  well  nourished  and  is 
slowly  rendered  a  less  and  less  fit  subject  for  an  abdominal 
section. 

The  abdomen  should  be  opened  in  the  median  line,  the 
cause  of  the  obstruction  sought  for,  and  the  involved  loop 
drawn,  whenever  possible,  outside  the  abdominal  cavity. 

What  operative  measure  is  carried  out  will  depend  upon 
the  condition  found. 

Simple  Stricture  of  the  Bowel. — (1)  A  simple  ring-like 
cicatricial  stricture  is  admirably  treated  by  the  operation  of 
enteroplasty.  This  measure  is  carried  out  in  precisely  the 
same  way  as  is  the  very  excellent  operation  of  pyloroplast}^ 

The  stricture  is  divided  by  means  of  an  incision  made  along 
the  margin  of  the  bowel  most  remote  from  the  attachment  of 
the  mesentery.  This  incision  is  parallel  to  the  long  axis  of 
the  bowel,  and  therefore  at  right  angles  to  the  line  of  the 
stricture.  The  incision  is  carried  well  into  the  bowel 
both  above  and  below  the  stricture.  The  interior  of 
the  gut  is  examined,  and  if  found  sound,  the  cut  made 
is  united  by  sutures  in  such  a  way  that  the  cicatrix  is  at 
right  angles  to  the  long  axis  of  the  bowel,  and  is  parallel 
Avirh  the  line  of  the  original  stricture.  The  wound  before 
suturing  is  longitudinal,  and  after  suturing  is  transverse. 
The  central  parts  of  the  open  wound  become  the  ends  of 
the  united  wound.  The  sutures  employed  are  a  continuous 
suture  of  the  mucous  membrane,  covered  in  by  a  close 
line  of  Lembert's   sutures,  which   take   up   the   serous   and 


528        TREATMENT    OF    STENOSIS    OF    SMALL    GUT. 

muscular  coats.  Exaniple,s  of  this  023eration  have  been  re- 
corded b}^  Pean,^  AUinghaui,!  and  others. 

Several  simple  strictures  of  the  bowel,  if  all  of  the  ring- 
like type  and  not  too  close  together,  may  be  treated  b}^  this 
simple  means. 

(2)  If  the  stenosis  involve  a  more  considerable  surface  of 
the  bowel  so  as  to  take  the  form  of  a  tubular  stricture,  or  to 
produce  marked  deformation  of  the  intestine,  the  operation  of 
enteroplasty  is  not  possible,  and  the  involved  segment  of  gut 
may  be  e.vrised. 

P^xcision,  however,  is  not  so  essential  in  simple  stricture  of 
the  bowel  as  it  is  in  cases  of  malignant  stricture.  If  many 
strictures  exist  the  whole  of  the  involved  section  of  the  l)owel 
may  be  excised  should  the  strictures  be  placed  close  together. 

In  such  a  case  of  multiple  strictin-e  of  the  lesser  bowel, 
Koeberle  excised  with   success  more  than  two   yards  of  the 

It  is  scarcely  possible  that  in  a  case  of  multiple  stenosis  all 
the  strictures  are  of  such  a  type  that  excision  is  demanded. 
One  stricture  may  demand  such  a  measure  while  the  others 
may  be  treated  by  enteroplasty. 

A  slight  degree  of  narrowing  of  the  bowel  ma}^  be  satis- 
factorily treated  by  divulsion  or  stretching  with  the  linger. 

The  method  of  resection  emploj^ed  must  depend  upon  tlie 
individual  taste  of  the  surgeon. 

The  most  perfect  method  is  that  by  a  clean  excision 
of  the  part  followed  by  a  close  suturing  together  of  the 
divided  ends. 

The  objections  to  this  procedvu'e  are  these :  The  operation 
involves  a  considerable  expenditure  of  time ;  in  one  of  the 
recorded  cases — which  ended  favourably — the  operation 
occupied  three  hours.  The  patients  upon  whom  these  opera- 
tions are  performed  are  seldom  in  a  condition  to  stand  a  very 
long  operation.  They  are  worn  out  with  pain  and  want  of 
proper  sleep,  and  are  weak  and  mal-nourished  owing  to  their 
inability  to  take  or  to  digest  sufficient  food.  In  the  second 
place,  the  difference  in  size  and  substance  between  the  bowel 
above  the  obstruction  and  that  below  it  renders  union  by 
direct  suture  difficult.  The  upper  end  of  the  bowel  is  dilated 
and  of  large  lumen,  while  its  walls  are  thick,  hypertrophied 
and  stiff.  The  gut  below  the  stricture  is  empty,  contracted 
and  soft,  and  has  comparatively  thin  walls.  The  gut  there- 
fore  at  the  line  of  suture  is  very  apt  to  kink  or  to  become 

*  Bull,  cle  VAcad.  de  Mid.,  1890,  p.  856. 

t  Lancet,  vol.  i.,  1891,  p.  15ol. 

+  Bull,  et  J\lem.  de  la  Soc.  de  Chir.  de  Paris,  1881,  p.  99. 


EXCISION    OF   INTESTINE.  529 

bent  in  an  angular  manner,  and  at  this  point  an  undesirable 
degree  of  pressure  is  prone  to  take  place. 

To  cope  with  these  difficulties  there  has  arisen  the  re- 
markable host  of  plates,  discs,  tubes,  cylinders,  buttons  and 
bobbins  which  are  used  at  the  present  day  in  the  union  of 
divided  bowel. 

This  is  not  the  place  to  discuss  the  merits  of  these  various 
instruments.  Briefly,  I  may  say  that  Murphy's  button  pre- 
sents advantages  which  cannot  be  overlooked.  Its  application 
is  most  simple,  it  can  be  fixed  in  place  in  a  few  minutes,  and  it 
holds  the  divided  ends  of  the  bowel  together  with  admirable 
firmness.*  Next  to  this  metallic  button  may  be  ranked  Mayo 
Robson's  bone  bobbin,  which  has  many  points  in  its  favour, 
not  the  least  being  the  fact  that  it  is  absorbable. 

In  the  majority  of  instances  of  stenosis  of  the  small  intes- 
tine in  which  the  strictured  part  is  excised  the  two  divided 
ends  of  the  gut  may  be  united  at  once  and  the  wound  in  the 
abdominal  wall  closed. 

If  the  operation  be  carried  out  at  the  proper  time,  i.e.  as 
soon  as  the  diagnosis  has  been  made,  this  immediate  comple- 
tion of  the  operation  should  always  be  possible.  In  the 
neglected  cases,  however,  it  is  very  usually  an  undesirable  or 
unattainable  measure. 

The  patient  in  these  long-delayed  operations  is  in  a  feeble 
condition,  the  obstruction  in  the  bowel  is  marked,  the  gut 
above  the  narrowed  segment  is  distended  and  loaded  with  foul 
contents.  There  has  probably  been  stercoraceous  vomiting. 
In  all  such  cases  the  operation  must  be  brief,  the  conditions 
are  not  suited  for  an  elaborate  plastic  measure,  the  distended 
bowel  must  be  emptied  of  its  contents  and  this  without  delay. 
To  effect  these  ends  two  measures  are  available :  it  may  be 
possible  to  short-circuit  the  sniall  intestine,  leaving  the  stricture 
untouched  at  the  summit  of  the  loop  produced  by  the  short 
circuit.  In  this  way  the  distended  bowel  is  relieved  and  the 
ill-consequences  of  an  artificial  opening  in  the  small  intestine 
are  avoided.  This  measure  may  be  carried  out  in  cases  which 
are  not  too  advanced,  and  in  those  in  which  a  fair  emptying 
of  the  bowel  has  been  obtained  by  means  of  the  washing  out 
of  the  stomach.  At  a  subsequent  operation  the  strictured 
part  may,  if  need  be,  be  excised. 

The  second  measure  consists  in  excising  the  stricture 
at  once,  and  in  establishing  an  artificial  opening  which  is 
closed  by  a  subsequent  operation.  This  procedure  is  adapted 
for  cases  in  which  a  considerable  distension  of  the  gut 
exists.     With  regard  to  the  former  of  these  two  measures  it 

*  The  value  of  Murdhy's  button  is  further  considered  on  p.  547. 
I  I 


530        TREATMENT    OF    STENOSIS    OF    SMALL    GUT. 

may  be  asked  :  Why  not  be  content  with  the  short  circuit 
alone,  and  why  trouble  to  remove  the  non-malignant  stricture  ? 
It  is  possible  that  the  short  circuit  alone  may  suffice,  but  it 
has  become  evident  that  the  opening  made  between  two  parts 
of  the  small  intestine  in  effecting  a  short  circuit  or  lateral 
anastomosis  is  not  always  to  be  relied  upon,  especially  when 
one  limb  of  the  bowel  is  much  dilated  at  the  time  of  the 
operation  (see  page  547).  The  opening  thus  made  is  apt  to 
contract.  Moreover,  the  bowel  is  formed  into  a  loop,  and  this 
loop  could  very  easily  give  further  trouble.  When  the  exci- 
sion is  contemplated  the  whole  loop  is  excised,  including  the 
stricture,  and  the  junction  made  by  the  short-circuiting  ;  the 
divided  extremities  of  the  bowel  are  then  united  end  to  end. 

The  end- to -end  union  of  the  bowel  is  much  more  satisfac- 
tory and  more  certain  than  is  any  form  of  lateral  anastomosis 
or  short-circuiting. 

It  is  only  fair,  however,  to  say  that  in  many  reported  cases 
of  short-circuiting  for  simple  stricture  of  the  bowel  no  further 
complications  have  appeared  after  the  operation.  The  ex- 
cision of  a  section  of  small  intestine  for  simple  stricture  is  a 
measure  which  must  not  be  hastily  decided  upon.  It  is  the 
best  measure  both  in  theory  and  in  practice,  but  it  may 
involve  a  more  extended  operation  than  that  demanded  by  a 
mere  lateral  anastomosis. 

(3)  The  strictured  part  may  be  unsuited  for  either  entero- 
plasty  or  for  excision.  The  bowel  at  the  narrowed  part  may 
be  bound  down  by  numerous  and  complex  adhesions,  the 
division  of  which  is  undesirable  or  impossible  ;  or,  on  the  other 
hand,  it  may  be  considered  essential  to  carry  out  the  minimum 
measure  which  will  give  relief,  in  spite  of  the  tact  that  the 
affected  portion  of  bowel  is  excisable.  In  these  two  classes  of 
case  a  short  circuit  may  be  made,  and  the  bowel  near  to  the 
stricture  above  united  to  the  bowel  below. 

In  cases  in  which  excision  is  for  any  reason  impossible  this 
measure  calls  for  no  criticism ;  but  in  cases  in  which  excision 
is  possible  it  is  well  to  remember  that,  as  a  complete  surgical 
measure,  excision  with  end-to-end  union  of  gut  is  far  prefer- 
able to  a  lateral  anastomosis  in  which  the  narrowed  part  is 
leit  untouched. 

Malignant  Stricture  of  the  Boiuel. — When  this  condition 
exists  every  reasonable  attempt  should  be  made  freely  to 
excise  the  involved  bowel,  together  with  a  V-shaped  portion  of 
the  mesentery  to  which  it  is  attached. 

The  excision  may  be  performed  at  the  first  operation  and 
the  ends  of  the  bowel  at  once  united  and  the  wound  in  the 
abdomen   closed.      This   is   the   ideal   operation,  and  is    the 


EXCISION    OF   INTESTINE.  531 

one  which  should  be  carried  out  in  all  suitable  cases.  If 
there  has  been  long-abiding  obstruction  with  much  distension 
and  overloading  ot  the  bowel,  one  or  other  of  the  following 
measures  may  be  adopted  :  A  short  circuit  may  be  made  to 
relieve  the  pressing  obstruction,  and  the  abdomen  be  then 
closed.  At  a  second  operation  the  involved  loop  is  exciseo 
and  the  ends  of  the  divided  bowel  are  at  once  united.  On 
the  other  hand,  the  diseased  section  of  the  intestine  may  be 
excised  at  the  first  operation  and  an  artificial  opening  estab- 
lished in  the  bowel  to  relieve  the  obstruction.  This  opening 
is  closed  at  a  subsequent  laparotomy. 

Stenosis  of  the  Boivel  produced  by  Adhesions. — In  these 
cases  the  adherent  gut  may  be  bent  upon  itself  (page  80),  or 
a  coil  of  bowel  may  be  fixed  into  the  form  of  a  loop,  (page  90), 
or  adjacent  coils  may  be  matted  together  by  numerous  and 
dense  adhesions  (page  94 ),  or  the  bowel  may  be  compressed 
by  contracting  adhesions,  or  narrowed  by  shrinking  of  the 
mesentery  (pages  88  and  100). 

It  is  impossible  to  discuss  in  detail  the  various  measures 
which  may  be  carried  out  in  the  numerous  combinations  of 
conditions  which  are  possible  in  these  forms  of  obstruction. 

In  the  simplest  cases  the  adhesions  are  divided,  and  the 
intestine  is  restored  to  a  normal  condition.  Bowel  which  has 
been  acutely  bent  upon  itself  is  set  free  ;  kinking  is  rendered 
impossible,  and  loops  in  the  intestine  which  have  been 
made  by  adhesions  are  broken  down. 

In  less  simple  cases  the  involved  part  of  the  bowel  may 
be  excised.  This  course  is  to  be  commended  in  cases  in 
which  a  comparatively  short  length  of  bowel  is  buried  in 
adhesions  which  maintain  it  in  a  deformed  position,  and 
which  cannot  be  satisfactorily  dealt  with  by  division.  In 
some  of  these  cases  there  is  a  fistula  bimucosa  (page  93). 

In  examples  in  which  the  adhesions  themselves  cannot  be 
dealt  with,  and  in  which  excision  of  the  involved  segment 
of  bowel  is  impossible  or  undesirable,  a  short  circuit  or  lateral 
anastomosis  must  be  carried  out,  whereby  the  bowel  above 
the  obstruction  is  united  to  the  gut  below  the  narrowed  part. 

When  the  case  has  been  long  neglected,  and  when  the 
bowel  above  the  stenosis  is  much  distended,  a  temporary 
artificial  opening  may  be  occasionally  demanded. 

Ohstrwction  by  iSfeoplasms  or  Foreign  Bodies. — In  these 
cases  the  neoplasm  may  be  growing  from  the  bowel  wall 
(page  259)  or  it  may  have  its  origin  entirely  outside  the 
intestine  upon  which  it  presses  (page  269).  Some  cases  of 
obstruction  due  to  foreign  bodies  and  gall  stones  may  be 
chronic  in  type,  and  may  come  under  the  present  category 


532  TREATMENT   OF    OBSTRUCTION   BY   NEOPLASMS. 

(page  191).     Under  this  section  may  be  included  certain  very 
rare  examples  of  internal  hernia  (page  102). 

In  the  case  of  a  tumcm'  growing  from  the  bowel  wall  the 
coil  of  gut  should  be  brought  outside  the  abdominal  wound 
and  opened.  Tumours  with  slender  pedicles  may  be  remoTed 
by  ligature  and  division  of  the  pedicles,  and  those  with  larger 
bases  by  excision  ot  a  portion  of  the  bowel  wall.  For  the 
latter  measure,  however,  the  area  of  attachment  of  the 
tumour  must  still  be  slight,  or  a  stenosis  of  the  intestine  will 
result. 

When  the  growth  has  an  extensive  attachment  to  the  bowel 
the  involved  part  of  the  intestine  must  be  excised.  This  measure 
may  or  may  not  be  associated  with  a  temporary'  artificial 
opening.  Such  an  opening  is  by  no  means  to  be  desired  in 
the  small  intestine,  and  should  only  be  made  when  urgent 
necessity  exists.  Such  a  necessity  Avould  be  present  when 
the  case  had  been  long  neglected,  Avhen  the  bowel  was  greatly 
distended  and  in  a  doubtful  and  precarious  condition  at  the 
site  of  the  obstruction,  and  when  the  patient  was  in  extremis. 

In  less  severe  examples  marlvcd  by  obstruction  s}Tnptoms 
it  may  be  desirable  to  meet  the  pressing  need  of  the  case  by 
performing  a  lateral  anastomosis,  and  by  removing  the  im- 
plicated loop  at  a  subsequent  operation. 

In  those  cases  of  tumour  of  the  bowel  in  which  excision 
is  impossible  or  inexpedient  a  short  circuit  should  be  estab- 
lished, and  if  the  tumour  be  non-malignant  the  relief  obtained 
by  this  measure  will  be  complete. 

When  the  obstruction  is  due  to  the  pressure  of  a  tumour 
outside  the  bowel  the  treatment  will  consist  either  in  re- 
moving the  tumour  or  in  establishing  a  short  circuit  so  as 
to  avoid  the  part  compressed. 

When  marked  symptoms  of  intestinal  obstruction  are 
present  it  would  be  most  undesirable  to  embark  upon  a 
tedious  operation  for  the  removal  of  a  tumour  outside  the 
gut.  In  such  case  the  immediate  need  of  the  case — the 
obstruction — may  be  met  by  making  a  short  circuit,  and  at  a 
later  period  the  removal  of  the  tumour  may  be  undertaken. 

In  a  certain  number  of  cases  the  removal  of  the  tumour 
may  be  impossible  or  inexpedient.  If  the  growth  be  malig- 
nant it  will  probably  be  lelt  and  the  operation  limited  to 
a  restoration  of  the  interrupted  intestinal  canal. 

In  the  matter  of  the  treatment  of  cases  in  which  the 
obstruction  is  due  to  foreign  bodies,  nothing  has  to  be 
added  to  what  has  been  said  upon  this  subject.  The  symp- 
toms of  obstruction  are  assumed  in  the  present  cases  to 
be  chronic,  the  treatment  therefore  to   be   more  deliberate. 


TREATMENT    OF    STENOSIS    OF    COLON.  533 

and  the  occasions  in  which  it  is  necessary  to  estabhsh  an 
artificial  opening  in  the  gut  to  be  very  few. 

The  cases  of  internal  hernia  have  been  already  alluded 
to  on  pages  ]06  and  115. 

B.  Stenosis  of  the  Colon. — The  conditions  in  the 
colon  that,  as  regards  treatment,  may  be  included  under 
this  title  are: — 1.  Stricture;  2.  Bending  of  the  adherent 
colon;  3.  Compression  by  adhesions;  4.  Obstruction  by 
neoplasms ;  5.  Compression  by  a  tumour  outside  the  gut ; 
6.  Some  enteroliths. 

Feeding. — In  the  early  stages  of  stenosis  of  the  colon, 
the  importance  of  careful  feeding  is  not  so  emphatically 
marked  as  it  is  in  cases  of  stenosis  of  the  small  intestine. 
Where  the  colon  is  concerned,  there  is  at  first  no  immediate 
connection  between  the  taking  of  food  and  the  occurrence 
of  pain.  Later  in  the  case,  anything  which  excites  peristaltic 
movements  is  apt  to  cause  pain,  and  thus  the  patient  feels 
more  uncomfortable  after  each  meal. 

The  pain  in  stenosis  of  the  colon  depends  upon  the 
excessive  peristaltic  movement  which  attends  the  attempt 
to  force  fsecal  matter  through  the  narrowed  part  of  the  colon. 
It  will  be  evident,  therefore,  that  the  less  bulky  the  fsecal 
matter  in  the  gut  and  the  more  fluid  its  consistence,  the 
less  distress  will  be  experienced  by  the  patient. 

As  soon,  therefore,  as  a  case  of  stenosis  of  the  colon  has 
advanced  to  the  stage  of  colic,  the  feeding  of  the  patient 
becomes  a  matter  of  moment. 

The  diet  must  be  of  the  most  digestiVjle  character,  and 
must  be  of  such  a  kind  as  to  leave  the  least  possible  debris 
in  the  bowel. 

If  the  patient's  teeth  be  imperfect,  he  should  discontinue 
to  eat  meat. 

Milk  is  seldom  tolerated  for  long  by  adult  patients.  It 
is  very  apt  to  lead  to  scybala. 

The  patient  should  take  his  food  in  small  quantities  and 
often.  He  should  take  time  over  his  meals  and  should  rest 
after  them. 

Any  existing  dyspepsia  must  be  attended  to. 

An  attack  of  obstruction  has  very  often  been  due  to 
the  blocking  of  the  stricture  by  a  mass  of  undigested  food. 
I  remember  the  case  of  a  patient,  who  had  been  long  under 
treatment,  and  in  whom  an  acute  obstruction,  demanding 
immediate  operation,  was  brought  about  by  the  eating  of 
some  pineapple.  When  I  opened  the  colon  a  mass  of 
undigested  vegetable  fibre  was  found  completely  to  block 
the  narrow  stricture. 


534  TREATMENT    OF    STENOSIS    OF    COLON. 

With  care  in  the  feeding,  it  is  surprising  for  how  long 
a  time  a  patient  can  be  kept  in  comparative  comfort,  and 
how  narrow  the  kimen  of  the  gut  may  be  when  the  part 
is  finally  exposed  by  operation. 

When  regulating  the  patient's  diet,  it  should  be  remem- 
bered that  the  residue  of  the  food  taken  will  ultimately 
have  to  pass  through  a  strait  in  the  colon  which  would 
probably  not  admit  the  little  finger. 

The  patient  is  a  little  disposed  to  think  lightly  of  the 
question  of  diet  because,  such  pain  as  he  has  does  not — at 
first  at  least — follow  so  closely  upon  the  taking  of  food  as 
to  lead  to  the  deduction  that  it  is  due  to  what  is  eaten. 

The  more  solid  the  contents  of  the  colon,  the  more 
marked  is  the  pain,  and  the  nearer  is  the  time  for  operation. 

Opium. — For  the  relief  of  the  pain  in  stenosis  of  the 
colon,  opium  offers  the  only  means.  It  is  best  administered 
in  the  form  of  a  hypodermic  injection  of  morphia.  I  think 
the  morphia  is  best  administered  alone,  and  that  no  advan- 
tage attends  the  use  of  morphia  with  atropine. 

The  use  of  the  drug  should  be  delayed  a,s  long  as  possible. 
and  the  amount  given  should  be  the  ver}'  least  which  will 
suffice  to  relicA^e  pain. 

An  operation  should  be  undertaken  before  the  pain  be- 
comes a  severe  or  pressing  s^^mptom. 

In  the  early  stages  the  slight  cohc  present  may  be  relieved 
by  belladonna  or  hyoscyamus,  or  warm,  dry  applications  to  the 
abdomen. 

Before  the  days  of  abdominal  surgery  opium  played  a  very 
prominent  part  in  the  so-called  treatment  of  chronic  intestinal 
obstruction.  Indeed,  in  not  a  few  instances,  this  drug  was 
supposed  to  have  effected  a  cure.  As  a  somewhat  extreme 
instance  of  this  reputed  effect  of  the  narcotic,  the  following 
case  may  be  quoted.  A  female,  aged  thirty-nine,  after  long- 
continued  pain  in  the  epigastrium,  began  to  vomit  and  to 
suffer  from  complete  constipation.  The  vomiting  was  severe 
and  was  for  seventeen  days  stercoraceous.  Indeed,  one  note 
during  the  progress  of  the  case  states  that  the  patient  vomited 
tour  to  five  pints  of  feeculent  matter  every  twenty-four  hours. 
No  aperients  were  given.  The  only  treatment  adopted  con- 
sisted in  the  use  of  opium  and  the  administration  of  enemata. 
The  latter  produced  no  effect.  At  last  the  bowels,  after  having 
been  absolutely  obstructed  for  nineteen  days,  were  opened 
spontaneously  and  the  patient  made  a  good  recovery.^ 

The  immense  quantity  of  morphia  that  can  be  tolerated  in 
some  chronic  cases  is  surprising.     Dr.  Blake  reports  the  case 

*  Lancet,  vol.  i.,  1868,  p.  284. 


APKHIENTS.  535 

of  a  man  whose  bowels  were  absolutely  confined  for  no  less 
than  eighteen  weeks.  He  began  early  in  the  case  to  take 
morphia,  and  before  its  conclusion  was  taking  twelve  grains 
of  the  alkaloid  every  day.  The  bowels  were  spontaneously 
relieved  before  death,  which  occurred  seven  days  after  this 
relief  of  the  obstruction. 

Aperients.— It  is  very  important  in  cases  of  stenosis  of  the 
colon  to  maintain  as  long  as  possible  a  free  action  of  the 
bowels.  If  the  utmost  attention  be  paid  to  the  feeding  the 
bowels  may  be  kept  acting  by  aperients  until  the  case  is 
well  advanced. 

Aperients  do  not  cause  pain  until  the  stenosed  part  has 
become  quite  narrow,  or  until  some  mass  of  undigested  food 
has  been  rudely  forced  into  the  stricture.  In  this  respect 
stenoses  of  the  colon  differ  from  like  conditions  in  the  small 
intestine.  Towards  the  end  of  the  case  anything  which 
excites  peristaltic  movement  causes  pain.  There  are  a  few 
exceptions  to  this,  and  I  have  known  it  possible  for  the 
patient  to  obtain  some  relief  from  aperients  almost  up  to 
the  period  of  absolute  obstruction  without  experiencing 
notable  pain.  Those  aperients  which  promote  a  liquid  con- 
dition of  the  stools  are  the  most  to  ha  commended.  Thus 
all  saline  aperients  are  used  with  advantage ;  calomel  and 
castor-oil  are  also  of  service.  Liquorice  powder  and  prepara- 
tions of  sulphur  are  among  the  least  satisfactory  of  the 
aperients  available.  The  patient  soon  learns  from  which 
aperient  he  can  obtain  the  greater  relief.  Violent  purgation 
is  to  be  avoided.  All  that  is  desired  is  a  daily  loose  action 
of  the  bowels.  In  many  and  many  a  case  a  condition  of 
acute  and  abrupt  obstruction  has  been  brought  about  by 
too  harsh  purgatives.  The  violent  peristaltic  action  induced 
has  forced  the  more  solid  contents  of  the  bowel  into  the 
strictured  part,  and  has  led  to  a  complete  blocking  of  the 
lumen  of  the  gut. 

In  other  instances  the  indiscreet  use  of  aperients  has 
led  to  a  colitis  which  has  added  immensely  to  the  patient's 
distress. 

Indeed,  in  the  following  case  it  may  not  be  unjust  to 
ascribe  the  patient's  death  to  the  aperients  she  took.  A 
woman,  suffering  from  long-continued  constipation,  depending 
upon  a  non-malignant  stricture  of  the  sigmoid  Hexure,  took 
castor-oil  and  other  powerful  drastic  piu'gatives.  This  treat- 
ment led  to  no  improvement,  but  induced  a  profuse  diarrhoea 
attended  by  great  prostration,  and  soon  followed  by  death. 
The  autopsy  revealed  the  circumstance  that  the  greater 
part  of  the  anterior  wall  of  the  ascending  colon  had  sloughed, 


536  TREATMENT    OF   STENOSIS    OF    COLON. 

fsecal   extravasation  being   only  prevented   by  the  adhesion 
of  the  omentum  over  the  necrosed  part."^ 

The  bowel  above  the  stenosed  part  is  always,  in  advanced 
cases,  in  a  condition  of  catarrh,  and  this  catarrh  is  capable 
of  being  considerably  exaggerated  by  the  indiscriminate 
use  of  aperients. 

I  performed  a  left  inguinal  colotomy  in  an  elderly  man 
for  intestinal  obstruction  depending  upon  cancer  of  the 
upper  part  of  the  rectum.  He  had  for  some  time  been 
treated  by  aperients  which  had  been  lavishly  employed, 
and  which  had  certainly  maintained  some  action  of  the 
bowels  without  great  discomfort.  The  bowel  emptied  itself 
after  the  colotomy,  and  then  it  became  evident  that  the 
colon  was  the  seat  of  a  quite  severe  catarrh.  Material  more 
or  less  fsecal  poured  incessantly  from  the  artificial  opening, 
together  with  an  increasing  quantity  of  mucus.  The  amount 
of  mucus  became  excessive,  and  I  saw  on  one  occasion  a 
breakfast-cupful  of  perfectly  clear  translucent  mucus  collected 
from  about  the  wound,  and  pressed  out  of  the  bowel  at 
the  morning  dressing.  This  colitis  continued  in  spite  ot' 
all  treatment,  and  led  to  the  patient's  death  some  ten 
days  after  the  operation.  There  seemed  reason  to  believe 
that  the  catarrh  of  the  bowel  had  been  at  least  aggravated 
by  the  powerful  purgatives  which  had  been  so  vigorously 
employed  before  the  operation. 

In  maintaining  an  action  of  the  bowels  in  cases  of  stenosis 
of  the  colon  enemata  are  of  considerable  service.  Indeed, 
they  should  be  regarded  as  the  main  means  of  clearing 
the  colon  of  its  contents  Aperients  are  needed  to  make 
the  motions  fluid,  and  enemata  effect  the  emptying  of  the 
bowel  by  inducing  peristalsis  in  the  lower  parts  of  it,  and 
by  actually  washing  its  contents  away.  It  is  well,  whenever 
possible,  to  rely  more  upon  enemata  in  these  cases  than 
upon  purgatives  given  by  the  mouth. 

There  are  different  methods  of  administering  enemata. 
In  the  majority  of  cases  the  ordinary  enema-pump,  or  syringe, 
is  all  that  is  required.  A  better  instrument  than  this,  how- 
ever, even  for  ordinary  purposes,  is  the  syphon  apparatus. 
This  consists  essentially  of  a  large  funnel,  to  which  is  attached 
a  long  indiarubber  pipe  ending  in  a  more  solid  tube  for 
introduction  into  the  rectum.  This  solid  tube  should  be 
about  six  inches  in  length.  Between  the  two  tubes  is  a  tap. 
In  the  administration  of  enemata  by  this  means  the  patient 
should  be  placed  in  such  a  position  as  to  reduce  the  ab- 
dominal pressure  as  much  as  possible.     The  knee-and-head, 

*  Case  by  Dr.  Moxon  ;  Path.  Soc.  Trans.,  vol.  xx.,  1869,  p.  181. 


ENEMATA.  537 

knee-and-elbow,  and  lateral  abdominal  positions  are  the  best. 
In  the  latter  posture  the  patient  should  lie  upon  the  left  side 
with  the  buttocks  well  raised.  The  water  enters  by  gravita- 
tion, and  the  pressure  of  the  entering  column  can  be  increased 
or  diminished  by  raising  or  lowering  the  fimnel  containing 
the  injection  material  This  method  has  great  advantages 
over  the  ordinary  syringe.  The  fluid  is  introduced  in  a 
constant  and  easily  regulated  stream,  and  not  in  intermittent 
ofushes.  The  bowel  beins^  more  tolerant  of  the  former 
method,  it  follows  that  much  larger  quantities  of  fluid  can 
be  introduced  by  this  means  than  by  the  common  syringe. 
The  pressure,  moreover,  that  is  exercised  upon  the  walls  of 
the  bowel  is  uniform  and  can  be  slowly  and  regularly  in- 
creased. The  height  at  which  the  funnel  is  carried  above  the 
level  of  the  patient's  body  should  vary  from  two  to  three  feet. 

The  material  used  in  the  enema  may  consist  of  warm 
water  or  of  warm  soap  and  water.  The  etflcacy  of  the  injec- 
tion is  often  much  increased  by  the  addition  of  a  little 
turpentine  to  the  soap  and  water  enema.  A  very  excel- 
lent enema  for  occasional  use  is  the  salt  enema  made 
by  adding  one  tablespoonfid  of  salt  to  one  pint  of  warm 
water. 

Injections  of  pure  olive  oil  are  often  of  service,  and  others 
advocate  enemata  partly  composed  of  oil.  I  do  not  think 
that  any  advantage  attends  the  use  of  enemata  to  which 
purgative  drugs  such  as  senna,  or  aloes,  have  been  added. 
The  enema  of  sulphate  of  magnesia  acts  merely  as  the  salt 
enema.  In  the  present  class  of  case  the  use  of  glycerine  as  a 
rectal  injection  is  of  no  service. 

The  amount  of  fluid  introduced  into  the  rectum  must  be 
regulated  by  the  sense  of  discomfort  experienced  by  the 
patient.  When  plain  warm  water  is  employed  one  to  three 
pints  may  be  used.  The  salt  enema  so  soon  stimulates  the 
bowel  that  the  amount  introduced  is  usually  limited  to 
one  pint.  If  oil  be  employed  the  quantity  may  be  also 
hmited  to  a  pint.  The  weight  of  the  oil  is  not  inconsider- 
able, and  it  can  be  made  to  exercise  considerable  pressure 
upon  the  bowel.  I  have  seen  three  pints  of  olive  oil  intro- 
duced into  the  colon  without  causing  distress  to  the  patient. 
These  "monster"  enemata  are  not  to  be  recommended. 
They  cause  distress  and  lead  to  over-distension  and  conse- 
quent exhaustion  of  the  bowel.  They  are  also  dangerous. 
It  is  needless  to  say  that  the  bowel  has  been  ruptured  by 
forcible  enemata,  and  in  a  case  of  advanced  cancer  of  the  colon 
low  down  on  the  left  side  a  perforation  of  the  bowel  at  the 
seat   of  the   stricture  could   be  easily  effected    by   a    quite 


538  TREATMENT    OF   STENOSIS    OF    COLON. 

moderate  injection.  It  should  be  remembered  that  the  gut 
below  the  stenosed  part  is  empty  and  contracted. 

Enemata  given  by  the  "  long  tube  "  are  most  distinctly 
to  be  avoided.  Considerable  damage  may  be,  and  has  been, 
done  by  the  long  tube.  It  has  been  already  pointed  out  that 
the  use  of  this  instrument  is  founded  upon  a  fallacy,  and  that 
it  cannot  be  passed  beyond  the  sigmoid  flexure.  In  cases  in 
which  the  rectum  is  obstructed  by  a  uterine,  prostatic  or 
pelvic  tumour  a  tube  of  extra  length  may  be  employed  in 
order  to  get  beyond  the  obstruction,  but  such  a  tube  should 
never  be  of  such  length  as  to  be  beyond  the  control  of  the 
surgeon's  fingers. 

In  long-standing  cases  of  obstruction  of  the  colon  I  have 
found  that  the  action  of  enemata  and  aperients  has  been 
much  promoted  by  hypodermic  injections  of  strychnia.  In 
the  adult  yl  oth  of  a  grain  of  strychnia  may  be  injected  three 
times  a  day  when  required. 

The  drug  should  be  given  hypodermically.  I  have  not 
observed  the  same  beneficial  effect  when  the  strychnia  has 
been  administered  by  the  mouth. 

In  certain  cases  massage  of  the  abdomen,  carried  out 
with  the  utmost  gentleness  and  caution,  may  prove  a  valuable 
aid  to  the  measures  already  described. 

As  an  example  of  its  use,  I  may  give  the  following  case : 
A  gentleman  of  sixty-three  came  under  my  care  with  chronic 
obstruction  of  the  intestines  and  with  an  obvious  collection 
of  fsecal  matter  in  the  descending  colon.  This  was  proved, 
at  a  subsequent  operation,  to  be  due  to  a  cancerous  stricture 
at  the  commencement  of  the  sigmoid  flexure.  Severe 
colic  was  complained  of;  the  abdomen  was  much  dis- 
tended, and  there  were  nausea  and  hiccough.  The  patient 
was  placed  upon  a  very  simple  diet.  Small  and  repeated 
doses  of  calomel  were  administered,  and  xioth  of  a  grain 
of  strychnia  was  injected  three  times  a  day.  Massage  of 
the  abdomen  was  employed  for  the  purpose  of  pushing  the 
f«cal  mass  bacliwards  towards  the  caecum,  and  so  of  relieving 
the  block  in  the  bowel.  This  measure  succeeded,  and  with 
the  aid  of  daily  enemata  the  bowel  was  ultimately  quite 
evacuated.  Under  careful  treatment  the  patient  remained 
in  comfort  for  three  months,  when  a  second  obstructive 
attack  made  imperative  an  operation  which  had  been 
hitherto  declined. 

Puncture  of  blie  Distended  Intestine. — in  cases  of 
obstruction  of  the  colon  from  any  cause  extreme  flatulent 
distension  of  the  belly  is  not  uncommon,  and  in  this  con- 
dition it  has  been  advised   that   an   aspirating  needle  or  a 


PUNCTURE    OF    THE    DISTENDED    INTESTINE.      539 

fine  trochtir  should  be  thrust  into  the  bowel.  This  measure 
has,  indeed,  been  many  times  carried  out,  and  considerable 
quantities  of  Hatus  and  even  of  fseces  have  been  evacuated. 
Moreover,  the  older  records  contain  accounts  of  cases  in 
which  cure  had  followed  upon  this  little  operation.  Even  in 
recent  times  one  now  and  then  meets  with  such  an  account 
as  the  following :  Mr.  Worthington  details  a  case  of  chronic 
constipation  ending  in  an  acute  attack  in  a  man  aged  twenty- 
eight.  The  symptoms  were  severe,  there  was  great  distension 
of  the  belly  and  stercoraceous  vomiting.  On  the  seventh  day 
a  fine  trochar  was  introduced  and  retained  for  thirty  minutes. 
Much  fluid  and  flatus  were  passed,  and  the  patient  made  a 
good  recovery.* 

It  is  probable  that  in  this  case  the  overloaded  bowel 
was  kinked  or  bent  upon  itself. 

Dr.  Blake  has  reported  a  case  of  constipation  which  was 
absolute  for  eighteen  weeks,  and  in  which  the  abdomen  was 
punctured  no  less  than  150  times,  about  half  a  pint  of  fteces 
being  drawn  off  each  time.     The  patient  died. 

This  mode  of  treatment  of  a  case  of  obstruction  by 
puncture  is  unscientific,  is  casual  and  speculative,  is  not 
free  from  danger,  and  is,  in  most  instances,  only  palliative. 
Before  the  use  of  puncture  be  considered  the  abdomen 
should  be  opened  and  the  condition  dealt  with  in  a  straight- 
forward manner.  The  tapping  of  the  bowel  through  an 
exploratory  incision  is  less  dangerous  than  the  tapping 
through  the  skin,  if  the  effect  of  an  anaesthetic  be  put  out 
of  question.  Tapping  of  the  bowel  may  be  carried  out  in 
cases  in  which  further  operation  is  declined,  and  in  cases 
which  may  be  regarded  as  hopeless.  As  an  example  of  the 
latter  condition,  I  may  mention  a  case  in  which  I  opened 
the  csecum  for  an  advanced  malignant  growth  of  the 
ascending  colon.  In  the  course  of  a  few  months  the  small 
intestine  became  involved  in  the  growth,  and  great  disten- 
sion of  that  bowel  followed.  The  patient  was  at  the  time 
saturated  with  morphia.  No  further  operation  could  be 
considered,  but  the  last  days  of  life  were  rendered  com- 
paratively comfortable  by  the  occasional  relief  of  the  dis- 
tended gut  by  tapping. 

Another  example  of  the  justifiable  use  of  tapping  may 
be  afforded  by  the  following  case.  I  was  called  to  see  a 
very  stout  woman,  in  whom  the  symptoms  of  subacute 
obstruction  had  supervened  upon  symptoms  of  a  chronic 
type.  In  due  course  it  was  discovered  that  a  stricture  of 
the   sigmoid   flexure   had   become   blocked.     The   distension 

*  Jirit.  McfL  Journ.,  vol.  ii.,  1882,  p.  1(37. 


540  TREATMENT    OF    STENOSIS    OF    COLON. 

of  the  belly  was  enormous ;  the  patient  could  not  lie  down, 
there  was  great  dyspnoea  and  some  cyanosis  of  the  ex- 
tremities. Much  morphia  had  been  given.  It  was  con- 
sidered out  of  the  question  to  attempt  to  administer  an 
anaesthetic.  I  therefore  punctured  the  bowel  through  the 
median  line,  and  allowed  an  immense  quantity  of  flatus  to 
escape.  The  distension  subsided,  and  the  patient  was  so 
relieved  that  an  anaesthetic  was  given  and  the  abdomen 
opened,  the  aspirating  trochar  having  been  retained  in  place 
until  the  gut  was  exposed. 

It  is  quite  obvious  that  in  any  case  of  stenosis  of  the 
colon  or  even  of  blocking  of  the  bowel  by  a  fsecal  mass, 
puncture  can  only  give  temporary  relief.  If  it  were  entirely 
without  danger  it  may  be  practised  without  criticism,  but 
as  a  matter  of  fact  leaking  of  the  over-distended  gut  at 
the  puncture  is  quite  likely  to  occur,  and  there  must  be  few 
surgeons  who  have  not  met  with  cases  of  fatal  peritonitis 
from  this  timid  little  operation. 

Treatment  by  Operation. — ^Under  this  heading  one  can 
only  repeat  what  has  been  written  respecting  operation  in 
stenosis  of  the  lesser  bowel.  When  once  the  diagnosis  is 
made  in  a  case  of  stenosis  of  the  colon,  the  sooner  the 
abdomen  is  opened  the  better.  There  is  seldom  any 
urgency,  but  it  must  be  realised  that  the  condition  cannot 
be  remedied  by  medical  measures,  and  that,  although  life 
may  be  extended  for  months  by  means  of  careful  treatment, 
the  condition  of  obstruction  becomes  more  and  more  marked 
and  the  state  of  the  patient  less  and  less  satisfactory.  At 
any  moment  the  narrowed  strait  in  the  bowel  may  become 
blocked,  and  a  condition  of  acute  obstruction  be  produced. 

There  is  no  possible  excuse  for  delaying  an  operation, 
while  every  fact  in  the  pathology  and  clinical  phase  of  the 
affection  is  an  argument  in  favour  of  early  operation. 

The  earlier  the  operation  is  performed  the  easier  it  is 
to  carry  out.  As  time  advances,  the  gut  above  the  stenosed 
part  becomes  greatly  distended  and  its  walls  greatly  thick- 
ened. It  becomes  less  easy  to  manage.  In  the  resection 
of  portions  of  the  colon,  the  main  difficulty  lies  in  the  dis- 
proportion in  size  between  the  bowel  above  the  obstruction 
and  the  bowel  below  it.  The  existence  of  any  degree  of 
accumulation  in  the  intestine  undoubtedly  adds  to  the  risk 
of  the  operation  and  also  to  its  difficulty. 

If  the  stenosis  be  due  to  a  malignant  growth  in  the 
colon,  delay  of  any  kind  is  utterly  to  be  condennied.  The 
Iree  excision  of  a  portion  of  the  colon,  the  seat  of  malig- 
nant disease,  is  an  operation  which  has  been  attended  with 


OPERATION.  541 

admirable  results.  Indeed,  it  appears  to  me  that  the  treat- 
ment of  cancer  by  excision  gives  better  results  when 
applied  to  the  colon  than  it  does  in  almost  any  other  part. 
The  excellence  of  the  result  depends  very  largely  indeed 
upon  the  early  period  of  the  operation.  To  delay  a  laparo- 
tomy in  a  case  of  cancer  of  the  colon  is  to  treat  the 
patient  very  badly,  and  to  deprive  him  of  his  only  chance  of 
recovery  or  of  long  immunity  from  disease. 

The  fact  that  delay  of  an  operation  is  possible  in  these 
cases  is  no  argument  that  such  delay  is  immaterial. 

This  branch  of  abdominal  surgery  will  have  made  a 
substantial  advance  when  the  rule  is  observed  that  the 
abdomen  should  be  opened  as  soon  as  the  diagnosis  has 
been  made  or  the  condition  is  reasonably  suspected  to 
exist. 

The  observations  already  made  upon  the  operative  treat- 
ment of  stenosis  of  the  small  intestine  apply  in  great  part 
to  the  present  subject. 

Stricture  of  the  Colon. — The  abdomen  is  most  con- 
venientl}^  opened  in  the  median  line,  except  in  instances  in 
which  the  position  of  the  stricture  is  well  defined  and  a 
conveniently  placed  incision  can  be  made  directly  over  the 
affected  part.  It  is  well,  however,  to  remember  that  almost 
any  part  of  the  colon,  except  perhaps  the  flexures,  can  be 
dealt  with  through  a  median  incision.  In  stout  patients 
the  abdominal  wound  is  better  placed  if  made  directly  over 
the  stenosed  part.  There  is  no  doubt  but  that  more  errors 
have  been  made  and  more  inconvenience  produced  by  in- 
cisions placed  over  the  supposed  site  of  the  stricture  than 
by  incisions  made  in  the  median  line.  The  diagnosis  of  the 
exact  site  of  the  stricture  cannot  always  be  made  with 
absolute  certainty.  The  operations  of  excision  and  of  short- 
circuiting  are  most  conveniently  carried  out  through  a 
median  incision.  A  median  incision  large  enough  to  admit 
two  fingers  allows  of  a  very  fair  exploration  of  the  abdomen. 
If  it  be  found  to  be  inconveniently  placed  for  the  operation 
which  is  indicated  it  can  be  readily  closed  and  an  incision 
made  in  the  place  pointed  out  at  the  examination. 

In  favour  of  a  median  incision  is  the  fact  that  strictures 
of  the  colon  are  sometimes  multiple.  In  a  reported  case 
of  obstruction  in  the  rectum  a  lumbar  colotomy  was  per- 
formed. It  proved  to  be  unavailing  because  an  obstruction 
also  existed  in  the  small  intestine.  Had  an  exploration  been 
made  through  the  median  line,  that  more  important  obstacle 
would  probably  have  been  discovered. 

I   am   not  aware   that   enteroplasty — or  coloplasty  as  it 


542  TREATMENT    OF    STRTCTURE    OF    COLON. 

Avould  be  called — has  been  applied  to  the  stricture  of  the 
colon,  although  it  has  been  successfully  performed  in  a  case 
of  stricture  at  the  ileo-csecal  valve. 

It  is  possible,  however,  that  cases  will  be  found  in  which 
this  simple  measure  may  be  carried  out. 

To  ensure  success  it  is  essential  that  the  stricture  should 
be  non-malignant,  that  it  should  be  of  quite  limited  extent 
and  ring-like,  and  that  the  bowel  at  the  affected  part  should 
be  free  and  well  co veered  by  peritoneum. 

Assuming  this  measure  not  to  be  practicable,  the  treat- 
ment which  may  be  carried  out  applies  with  almost  equal 
appropriateness  to  both  simple  and  malignant  strictures. 

The  seat  of  disease  having  been  exposed,  the  affected  part 
of  the  bowel  should  be  drawn  without  the  abdominal  wound 
whenever  possible,  and  in  any  case  brought  as  near  to  the 
surface  as  its  attachments  will  permit. 

The  caecum  and  the  central  parts  of  the  transverse  colon 
and  sigmoid  flexure  can  in  most  instances  be  drawn  outside  a 
median  incision. 

The  ideal  operation  consists  in  the  removal  of  the 
strictured  part  and  the  immediate  union  of  the  divided  ends 
and  closure  of  the  abdominal  wound. 

If  the  stricture  be  malignant,  the  excision  of  the  part  of 
the  bowel  invaded  is  greatly  to  be  desired.  If  the  stricture  be 
non-malignant,  the  best  operation  consists  in  the  removal  of 
the  narrowed  part,  assuming  coloplasty  not  to  be  possible  or 
expedient. 

In  the  case  of  a  simple  stricture,  excision  of  the  part  with 
end-to-end  union  of  the  colon  is  an  infinitely  more  satisfactory 
operation  that  the  measure  of  short-circuiting.  Many  after- 
troubles  may  beset  a  case  which  has  been  merely  treated  by  a 
short-circuiting  operation.  The  immediate  obstruction  in  the 
bowel  is  relieved,  but  the  state  of  thinsfs  left  in  the  abdomen 
is  hardly  satisfactory. 

The  opening  made  by  the  lateral  anastomosis  is  apt  to 
contract,  or,  at  least,  is  infinitely  more  prone  to  become 
narrowed  than  is  the  line  of  juncture  in  an  end-to-end  union 
of  the  bowel.  Then  material  may  readily  pass  into  the  loop 
which  is  excluded  from  the  main  intestinal  passage.  This 
loop  may  become  a  diverticulum  in  which  faecal  matter  may 
collect  and  may  give  rise  to  colic,  to  catarrh,  to  ulceration  and 
the  other  evils  which  attend  the  retention  of  faeces.  In  this 
particular  the  colon  differs  materially  from  the  small  intestine. 
The  contents  of  the  lesser  bowel  are  fluid,  and  such  incon- 
venience as  has  just  been  mentioned  is  not  likely  to  occur 
when  a  portion  of    that    intestine    is    short-circuited.      The 


8E0KT-CURCUITING.  543 

contents  of  the  colon,  on  the  other  hand,  are  sohd  or  semi- 
soKd,  and  readily  become  inspissated  when  long  retained. 
The  stricture  may,  after  the  channel  for  faeces  has  been 
diverted,  become  practically  impervious,  and  material  finding 
its  way  into  the  loop  may  be  unable  to  escape.  It  is  remark- 
able how  seldom  troubles  do  arise  after  a  short  circuit  has 
been  made  in  the  colon,  but  they  do  occur  with  sufficient 
frequency  to  make  the  fact  undoubted  than  an  end-to-end 
junction  of  the  bowel  after  excision  is  an  infinitely  preferable 
method  to  short-circuiting. 

Numerous  instances,  however,  occur  in  which  excision  of 
the  stenosed  part  and  immediate  suture  are  not  possible. 

(1)  In  the  first  place  must  be  mentioned  the  cases  which 
are  associated  with  a  marked  degree  of  obstruction. 

Such  cases  are  not  suited  for  a  long  operation  nor  for  one 
of  a  plastic  character.  The  colon  above  the  stricture  is 
greatly  distended  and  is  loaded  with  decomposing  fsecal 
matter.  The  patient  is  probably  pro.'^trated  by  pam,  vomiting, 
want  of  sleep,  and  want  of  food.  The  disproportion  in  size 
between  the  gut  above  the  obstruction  and  that  below  is  at 
its  maximum.  In  these  examples  the  first  indication  is  to 
reUeve  the  intestinal  obstruction,  and  to  do  that  with  the 
least  amount  of  disturbance  to  the  patient.  The  bowel, 
therefore,  may  be  short-circuited  or  a  colotomy  may  be 
performed. 

Of  these  two  measures,  the  former  is  the  one  to  be  aimed 
at  whenever  possible.  It  saves  the  patient  even  a  temporary 
artificial  anus,  and  if  a  subsequent  operation  be  carried  out 
the  excision  is  more  easily  done  when  a  short  circuit  has  been 
made  than  when  there  is — -an  addition  to  the  resection — an 
opening  in  the  bowel  to  be  closed. 

In  the  most  extreme  cases,  those  in  which  the  distension 
is  considerable,  and  in  which  the  patient's  condition  causes  the 
greatest  anxiety,  in  cases,  in  fact,  which  have  been  grossly 
neglected,  a  colotomy  alone  must  be  done.  It  is  the  less 
severe  of  the  two  measures  under  discussion  and  can  be 
carried  out  with  the  less  expenditure  of  time.  Indeed,  in  one 
extreme  case  I  performed  a  left  inguinal  colotomy  without 
any  anjiesthetic  except  a  little  cocaine  under  the  skin. 

I  have  effected  a  short  circuit  in  cases  attended  with 
obstruction  phenomena  of  an  advanced  type  and  have  been 
very  satisfied  with  the  result.  In  operations  done  under  these 
conditions  the  method  by  Murphy's  button  has  certainly  dis- 
tinct advantages  on  account  of  the  rapidity  with  which  the 
union  can  be  carried  out  and  the  security  with  which  the 
portions  of  bowel  may  be  fixed  together.       When  the  selected 


544  TBEATMENT    OF   STRICTURE    OF    COLON. 

portions  of  the  colon  are  in  position  the  operation  of  short- 
circuiting  may  be  completed  within  ten  minutes. 

If  the  case  be  one  of  non- malignant  stricture  the  one 
operation  of  short-circuiting  may  suffice,  and  the  patient  may 
remain  Iree  of  any  further  intestinal  trouble.  If  the  stricture 
be  malignant,  then  the  excision  which  is  essential  can  be,  as 
already  stated,  more  conveniently  carried  out  when  a  short 
circuit  has  been  eti'ected,  than  when  a  colotomy  wound 
exists. 

(2)  In  the  second  place  excision  may  be  rendered  impossi- 
ble or  undesirable  on  account  of  the  condition  ot  the  affected 
gut.  The  colon  may  be  very  adherent,  and  it  may  be  scarcely 
possible  to  set  it  free.  The  strictured  part  may  be  the  centre 
of  a  mass  of  adhesions.  In  one  case  I  was  prevented  from 
attempting  an  excision  by  the  fact  that  coils  of  small  intestine 
had  become  adherent  to  the  surface  of  the  affected  gut,  which 
was  the  seat  of  a  cancerous  stricture. 

There  may  be  a  considerable  mass  of  inflammatory  thick- 
ening around  the  bowel  the  result  of  a  threatened  perforation, 
and  with  such  evidences  of  inflammation  an  actual  abscess 
may  be  associated. 

To  effect  a  ready  and  satisfactory  union  of  a  divided 
colon  it  is  desirable  that  the  serous  coat  of  the  bowel  should 
be  sound  and  complete.  Indeed,  when  a  very  rapid  operation 
has  to  be  carried  out  a  sound  and  normal  peritoneal  coat  is 
demanded.  If  a  large  surface  of  the  bowel  has  been  depriverl 
of  peritoneum,  very  close  suturing  is  essential,  and  even  then 
the  possibility  of  leaking  is  not  inconsiderable. 

The  mobility  of  the  colon  is  not  great  in  parts  other  than 
the  sigmoid  flexure  and  transverse  colon  ;  and  before  the  gut 
is  excised  it  must  be  made  manifest  that  the  divided  ends  can 
be  brought  together  without  strain  on  the  one  hand,  and 
without  undue  disturbance  of  parts  on  the  other.  Xow  and 
then,  in  the  case  of  a  non-malignant  stricture,  a  considerable 
portion  of  the  bowel  is  involved,  is  narrowed,  is  puckered  and 
contorted,  or  is  firmly  bound  down.  To  restore  the  canal  in 
a  satisfactory  manner,  the  excision  of  some  inches  of  the  gut 
may  be  demanded,  but  so  liberal  a  removal  of  parts  may  be 
inconsistent  with  a  satisfactory  joining  of  the  divided  ends. 

If  a  malignant  growth  has  invaded  the  tissues  outside  the 
bowel,  it  is  needless  to  say  that  an  attempt  at  excision  is  not 
justified. 

The  course  to  be  adopted  in  those  cases  in  which  excision 
with  immediate  suturing  of  the  bowel  is  rendered  impossible 
by  the  condition  of  the  gut,  will  vary.  If  the  stricture  be 
non-malignant,  a  short  circuit  will  be  indicated ;  and  should 


COLO  TO  MY.  545 

that  bo  impossible,  there  is  nothing  to  be  done  but  to  com- 
plete the  operation  by  a  colotomy. 

There  will  be  but  few  cases,  however,  in  which  this  will  be 
necessary.  In  the  (-ase  of  a  malignant  stricture  two  courses 
are  open.  The  growth  may,  on  the  one  hand,  be  left  untouched, 
and  a  short  circuit  be  established,  or  a  colotomy  carried  out, 
according  to  the  possibilities  of  the  case ;  on  the  other  hand, 
the  mass  may  be  excised,  and  a  colotomy  established,  any 
attempt  at  union  being  out  of  the  (question.  In  the  operation, 
the  position  of  the  colotomy  wound  must  depend  upon  the 
situation  of  the  growth.  The  involved  segment  of  the  colon 
nnist  be  diawn  without  the  wound,  must  be  liberally  excised, 
and  a  permanent  opening  in  the  bowel  established.  It  thus 
happens  that  when  such  an  excision  is  carried  out  on  the 
ascending  and  descending  colon,  the  colotomy  wound  is  best 
placed  in  the  lumbar  region. 

It  may  be  argued  that  if  the  affected  bowel  can  be  drawn 
outside  the  parietal  wound  a  union  by  suturing  could  be 
effected  after  excision,  but  experience  shows  that  this  is  not 
to  be  inferred.  To  carry  out  a  sound  and  safe  union  of  the 
divided  colon  considerable  laxity  in  the  two  ends  of  the 
bowel  is  demanded.  Moreover,  in  effecting  a  short  circuit 
there  must  be  no  strain  upon  the  parts  which  have  been 
united.    The  two  portions  of  bowel  must  come  easily  together. 

The  possibilities  of  effecting  a  short  circuit  are  rendering 
colotomy  for  stenoses  of  the  colon  less  and  less  common.  In 
many  cases  of  malignant  disease  of  the  colon,  in  which  I  was 
unable  to  excise  the  mass,  complete  relief  has  been  given  by  a 
short  circuit,  and  the  patient  has  been  spared  the  discomfort 
of  a  colotomy  wound. 

Colotomy. — The  common  and  useful  operation  of  colotomy 
has  been  greatly  improved  within  the  last  few  years  and  has 
been  rid  of  most  of  the  after-discomforts  which  made  it  at  one 
time  a  measure  to  be  greatly  dreaded.  The  operation  in  the 
iliac  region  has  entirely  supplanted  the  colotomy  in  the  loin, 
and  the  latter  procedure  has,  indeed,  become  one  of  the 
rarest  of  abdominal  operations.  In  inguinal  colotomy  pains 
have  to  be  taken  to  select  a  proper  spot  for  the  opening  in  the 
sigmoid  flexure,  the  bowel  must  be  carefully  fixed,  and,  in  my 
experience,  the  best  results  have  attended  the  immediate 
opening  of  the  gut,  the  content's  being  evacuated  through  a 
glass  tube.  Little  or  nothing  is  now  seen  in  practice  of  two 
after-troubles  which  were  at  one  time  the  bugbears  of 
colotomy — viz.  the  contraction  of  the  orifice,  on  the  one  hand, 
and  the  prolapse  of  the  exposed  bowel  on  the  other.  The 
average  colotomy  gives  the  patient  but  a  minimum  amount  of 
J  J 


546  TREATMENT    OF    STRICTURE    OF    COLON. 

trouble.  In  a  large  proportion  of  cases  it  is  possible  to  secure 
a  good  action  oT  the  bowels  every  forty-eight  hours,  the 
artificial  opening  causing  the  patient  but  little  or  no  incon- 
venience in  the  interval.  If  there  be  a  degree  of  colitis 
present  at  the  time  of  the  operation  it  is  true  that  the  new 
opening  may  be  the  seat  of  not  inconsiderable  distress.  But 
in  the  average  case  the  administration  of  a  dose  of  mistura 
alba  very  early  in  the  morning  on  alternate  days  will  secure 
an  ample  evacuation  of  the  bowel,  followed  by  a  period  of 
immunity  from  disturbance.  This  much-to-be-desired  result 
is  rendered  possible  by  very  careful  feeding  and,  above  all,  by 
the  utmost  attention  to  the  wound. 

There  is  no  doubt  but  that  the  troubles  attending  colotom}^ 
as  performed  some  years  ago,  were  in  large  measure  due  to 
neglect  of  the  wound.  A  pad  of  septic  tow  and  a  dab  of 
vaseline  were  placed  over  the  bowel  and  the  requirements 
of  surgery  were  considered  to  have  been  thereby  fully  met. 
The  gross  neglect  ot  the  part  was  excused  on  the  ground 
that  the  operation  area  was  already  septic.  As  a  matter 
of  fact,  few  complicated  wounds  respond  more  readily  to 
careful  treatment  and  assiduous  attention  than  does  the 
colotomy  incision,  and  the  benefit  to  the  patient  from 
such  care  can  hardly  be  overestimated.  I  am  convinced 
that  the  troublesome  catarrh  of  the  colon  which  was  not 
uncommon  after  colotomy  was  very  often  due  to  the  filthy 
condition  into  which  the  wound  was  allowed  to  pass,  and  that 
difficulty  with  the  bowel  in  the  form  of  prolapse  was  often 
dependent  upon  the  same  cause. 

The  Union  of  Divided  Bowel. — It  would  be  out  of  place 
to  discuss  in  such  a  work  as  the  present  the  various  methods  of 
uniting  divided  bowel.  This  matter  is  fully  considered  in  the 
numerous  works  on  operative  surgery.  I  would  only  venture 
upon  a  few  points  of  criticism. 

Of  the  methods  of  uniting  divided  bowel,  either  after 
excision  or  in  the  performance  of  a  lateral  anastomosis,  the  best 
theoretically  is  without  doubt  the  method  of  simple  suturing. 
In  practice,  however,  this  can  seldom  be  advantageously  em- 
ployed. The  simple  suture  involves  a  great  expenditure  of 
time ;  the  differences  in  the  segment  of  gut  above  the  stricture 
and  that  below  it  render  straightforward  suturing  almost 
impracticable ;  the  bowel  at  the  suture  line  is  very  apt  to  kink. 
To  cope  with  these  difficulties  there  has  arisen  the  remarkable 
host  of  plates,  discs,  tubes,  cylinders,  buttons,  and  bobbins 
which  has  so  disturbed  the  peace  of  the  surgeon  who  hungers 
after  the  "  last  new  thing." 

Of  the   various  appliances  in  vogue   for   the   uniting   of 


UNION   OF   DIVITJED    GUT.  547 

divided  bowel  I  think  one  of  the  best  is  Murphy's  button.  It 
is  very  far  from  being  a  perfect  instrument,  but  it  compares 
at  least  very  favourably  with  the  other  forms  of  apparatus 
which  compete  with  it. 

I  have  employed  MurjDhj^'s  button  in  considerably  over 
fifty  cases  with  results  which  are  certainly  satisfactory.  The 
button  requires  no  elaborate  preparation ;  it  is  always  ready ; 
its  introduction  is  exceedingly  simple,  and  is  effected  in  a  few 
minutes.  The  two  parts  of  the  instrument  may  certainly 
jam,  but  I  think  that  this  accident  is  the  result  of  careless 
handling.  I  have  never  known  it  to  induce  a  gangrene 
which  has  extended  beyond  the  limit  of  the  button. 

The  two  definite  and  undoubted  objections  to  the  button 
are  these :  it  may  be  indefinitely  retained,  and  its  separation 
may  be  followed  by  contraction  of  the  artificial  opening. 

These  two  undesirable  results  are  often  in  close  relation 
to  one  another  as  cause  and  effect.  In  the  cases  of  cholecyst- 
enterostomy  in  which  I  have  used  the  button  I  have  never 
known  it  to  be  retained  and,  so  far  as  I  am  aware,  the 
opening  made  has  not  undergone  inconvenient  contraction. 
In  cases  in  Avhich  the  button  has  been  employed  in  the 
colon  only  I  have  never  had  it  retained,  but  in  some 
instances — a  very  small  minority — there  has  been  contrac- 
tion of  the  new  passage.  In  examples  of  gastro-enter- 
ostomy  performed  by  means  of  this  apparatus  retention  ot 
the  button  for  considerable  periods  or  its  absolute  failure  to 
appear  at  all  seems  to  me  to  be  the  rule  rather  than  the 
exception.  In  not  a  few  instances  there  has  been  undoubted 
contraction  of  the  artificial  opening.  In  only  two  examples 
of  gastro-enterostomy  in  which  the  button  was  retained  has 
that  instrument  caused  any  trouble. 

As  an  example  of  contraction  of  the  colon  after  the  use  ot 
the  button  I  may  mention  the  following  case.  A  man,  aged 
sixty-one  years,  who  had  had  symptoms  of  chronic  intestinal 
obstruction  for  some  months,  was  seized  with  symptoms  of 
acute  occlusion  of  the  bowel,  attended  by  immense  disten- 
sion of  the  abdomen  and  stercoraceous  vomiting.  Laparo- 
tomy, performed  in  January,  1897,  revealed  an  epithelioma 
in  the  centre  of  the  sigmoid  flexure.  The  urgency  of  the 
case  and  the  great  distension  forbade  any  attempt  at 
excision.  I  therefore  effected  an  anastomosis,  by  means  of 
a  Murphy's  button  of  the  largest  size,  between  the  two 
extreme  ends  of  the  sigmoid  flexure.  The  diameter  of  the 
button  was  one  inch  and  a  half.  Fluid  faeces  were  passed 
before  the  patient  left  the  table,  and  he  was  at  once  relieved.. 
The  button,  which  had  already  been  used  in  two  previous  cases, 


548  TBEATMEXT    OF    STBICTURE    OF    COLON. 

was  passed  on  the  twenty-second  da}^  The  patient  was  walk- 
ing out  of  doors  at  the  end  of  the  fourth  week.  In  March, 
1897,  he  had  regained  his  ori^nal  weioht,  and  his  bowels 
were  acting  well  with  aperients.  I  then  performed  a  second 
laparotomy  to  remove  the  sigmoid  flexure.  Although  onW 
thirty-eight  days  had  elapsed  since  the  passing  of  the  button 
I  found  the  artificial  opening  I  had  made  so  contracted  that 
it  would  do  no  more  than  admit  my  little  finger.  I  removed 
the  whole  sigmoid  flexure  and  united  the  descending  colon 
to  the  rectum  by  means  of  the  same  button.  This  button 
was  passed  on  the  sixteenth  day.  The  patient  recovered 
rapidly  and  remains  in  sound  and  vigorous  health. 

The  explanation  of  these  cases  of  contraction,  whether  in 
the  stomach  or  in  the  colon,  is  not  far  to  seek.  The  button 
effects  an  o]3ening  between  the  two  viscera  by  means  of 
pressure  gangrene.  I  have  noticed  that  after-contraction 
has  only  occurred  in  cases  in  which  the  upper  viscus  was 
much  dilated  at  the  time  of  the  operation.  It  is  needless  to 
say  that  in  gastro-enterostomy  for  pyloric  obstruction  a  dilated 
stomach  is  met  with,  and  in  intestinal  anastomosis  for  stricture 
the  upper  segment  of  the  gut  is  apt  to  be  enormously  dis- 
tended. After  the  operation  the  dilated  organ  contracts  and 
consequently  the  newly-made  hole  contracts.  I  can  easily 
imagine  that  a  hole  in  a  dilated  stomach  made  by  pressure 
gangrene  and  of  the  size  of  half  a  crown  ma}^  readily  become 
an  aperture  of  the  size  of  a  fourpenny-piece  when  the  dis- 
tended viscus  has  gradually  contracted.  It  is,  therefore,  very 
desirable  to  have  the  viscera  to  be  dealt  with  as  empty  as 
possible  before  the  button  is  introduced.  This  end  is  very 
difficult  to  secure  even  in  a  partial  degree.  The  stomach,  for 
example,  in  old  pyloric  obstruction,  even  when  kept  washed 
out  for  many  days,  is  slow  to  contract,  and  if  at  the  time  of 
the  operation  the  viscus  be  still  much  dilated,  retention  of 
the  button  and  some  inconvenient  contraction  of  the  new 
opening  may  be  regarded  as  possible.  This  association  be- 
tween previous  distension  of  a  viscus  and  the  subsequent 
contraction  of  the  aperture  made  in  it  is,  of  course,  by  no 
means  limited  to  Murphy's  button.  It  applies  to  nearly 
every  method  in  vogue  for  carrying  out  the  operations  now 
under  discussion. 

In  employing  Murphy's  button  in  the  colon,  it  is  desirable 
that  the  passage  below  the  point  of  insertion  should  be  clear. 
Thus,  in  one  case  in  Avhich  I  short-circuited  the  colon  for 
malignant  disease  there  was  a  stricture  of  the  rectum  near 
the  anus,  due  to  an  extensive  operation  for  fistula.  This  pre- 
sented a  serious  obstacle  to  the  final  removal  of  the  button. 


UNION    OF   DIVIDED    GUT.  549 

In.  another  example  the  growth  for  which  the  short  circuit 
was  made  extended  into  the  pelvis,  and,  had  the  large-sized 
button  been  used,  it  would  hardly  have  escaped.  In  this 
instance  a  bone  bobbin  was  employed.  In  any  case  the  bone 
bobbin  is  a  useful  appliance,  and  in  the  hands  of  many 
surgeons  has  proved  t,o  be  of  great  value. 

Forms  of  Stenosis  other  than  Stricture. — The  varieties 
of  obstruction  of  the  colon  which  come  under  this  heading 
are  alluded  to  on  page  408. 

The  colon  may  be  adherent  and  be  bent  upon  itself, 
and  fixed  in  the  bent  position  by  adhesions,  or  the  gut 
may  be  actually  compressed  by  a  mass  of  adhesions  which 
pass  across  its  free  surface. 

In  such  cases  it  may  be  possible  to  divide  the  adhesions 
and  to  set  the  bowel  free.  Care  should  be  taken  in  carry- 
ing out  this  desirable  operation  to  see  that  the  colon  is 
really  set  free,  and  it  may  be  necessary  by  suturing  the 
mesocolon  or  by  other  n'leasures  to  fix  the  intestine  in  such 
a  position  that  the  distortion  cannot  be  repeated.  In  one 
case  in  which  a  considerable  raw  surface  was  left  after 
the  division  of  adhesions  I  covered  the  area  with  omentum 
which  was  already  adherent  in  the  vicinity.  This 
omentum  was  secured  in  place  by  fine  silk  sutures.  A 
perfectly  free  omentum  should  not  be  employed  for 
such  a  purpose,  and  I  am  not  sure  that  excised  portions 
of  omentum    ("omental  grafts")  are  to  be  depended  upon. 

If  the  adhesions  in  these  cases  cannot  be  satisfactorily 
dealt  with,  the  alternatives  will  have  to  be  considered  of 
an  excision  of  the  involved  part  with  inmiediate  suture,  on 
the  one  hand,  or  a  short  circuit  on  the  other.  The  case 
must  be  very  exceptional  in  which  one  or  other  of  these 
two  measures  cannot  be  carried  out.  I  am  not  aware  of  a 
recent  instance  of  this  form  of  obstruction  in  which  a 
colotomy  represented  the  only  means  of  treatment. 

Obstruction  of  the  colon  by  a  neoplasm  can  be  dealt 
with  by  a  more  or  less  obvious  series  of  operations  which 
will  meet  the  various  possibilities  encountered.  An  innocent 
pedunculated  tumour  may  be  removed  through  an  incision 
in  the  bowel  wall,  which  incision  is  at  once  closed. 

If  the  pedicle  be  broad,  the  operation  may  involve  the 
excision  ot  a  part  of  the  bowel  wall,  such  excision  being  of 
necessity  very  lunited  in  extent  owing  to  the  possibility  of  a 
stricture  resulting  therefrom.  In  the  case  of  large  and 
sessile  tumours  excision  of  the  portion  of  bowel  in  which  the 
neo]ilasm  is  growing  is  indicated.  Failing  such  excision, 
Qothing  remains  but  a  short-circuit  operation  or  a  colotomy. 


550     TREATMENT    OF    CHRONIC    INTUSSUSCEPTION. 

In  extensive  malignant  tumours,  such  as  lympho-sarco- 
mata,  an  excision  of  the  colon  will  hardly  be  indicated. 

When  an  excision  has  been  carried  out,  a  temporary 
artificial  opening  may  be  desirable  in  cases  associated  with 
advanced  obstruction  symptoms.  Or,  on  the  other  hand,  the 
bowel  with  the  tumour  may  be  excised,  with  the  understand- 
ing that  a  permanent  artificial  anus  will  be  unavoidable  after 
the  removal. 

When  the  colon  is  obstructed  by  the  pressure  of  a  tumour 
outside  its  walls,  the  operation  needed  to  give  relief  must  be 
liable  to  much  variation. 

In  a  certain  number  of  cases  the  obstruction  is  relieved  by 
the  entire  removal  of  the  tumour.  At  the  time  of  the  opera- 
tion, however,  the  bowel  must  be  fairly  free.  It  is  most 
undesirable  to  attempt  the  excision  of  a  large  extra-intestinal 
tumour  at  a  time  when  the  bowel  is  overloaded  and  actually 
obstructed.  As  an  instance  of  this  may  be  given  a  case  in 
which  a  large  uterine  fibroid  had  so  grown  as  periodically  to 
obstruct  the  colon  by  pressure.  For  this  and  other  reasons 
the  removal  of  the  uterus  was  considered  necessary.  Con- 
siderable care  had  to  be  expended  in  washing  out  the  colon 
as  a  preliminary  to  the  hysterectomy. 

The  removal  of  a  large  uterine  tumour  in  the  presence 
of  even  a  mild  degree  of  intestinal  obstruction  would  be  an 
unsurgical  proceeding. 

If  the  tumour  which  has  caused  the  obstruction  cannot 
be  removed,  nothing  remains  but  to  carry  out  a  short-circuit 
operation  or  a  colotomy.  In  these  particular  cases  a  short 
circuit  can  very  rarely  be  effected,  and  a  colotomy  becomes 
the  only  measure  of  treatment. 

In  cases  of  obstruction  due  to  enteroliths  the  bowel  wall 
is  incised  and  the  stone  removed. 

The  mode  of  completing  the  operation  will  depend  upon 
the  condition  of  the  bowel.  If  it  be  sound,  the  incision  is 
closed  by  suture  and  the  bowel  returned.  If  the  bowel  wall 
present  evidences  of  injurious  pressure,  a  temporary  artificial 
anus  may  have  to  be  made  or  a  portion  of  the  affected  gut 
may  have  to  be  excised. 

The  need  of  an  excision  in  these  cases,  however,  will  be 
very  unconnnon. 

C.  Chronic  Intussusception. — This  subject  has  been 
to  some  extent  dealt  with  in  the  section  on  the  treatment 
of  acute  intussusception. 

In  chronic  intussusception,  the  feeding  of  the  patient 
is  a  matter  of  extreme  iujportance,  and  is  carried  out  upon 
the  lines   already   laid   down   in   dealing   with  strictures   of 


OPERATION.  551 

the  small  intestine  and  of  the  colon  (pages  523  and  533). 
Anything  which  excites  peristaltic  action  excites  more  or  less 
distress,  and  the  higher  up  the  small  intestine  is  involved 
in  the  invagination,  the  more  marked  is  the  discomfort 
after  food. 

In  one  or  two  cases  in  which  vomiting  was  a  marked 
symptom  considerable  relief  attended  the  washing  out  of 
the  stomach. 

Paroxysms  of  pain  must  be  relieved  by  opium,  the  rule 
being  observed  to  give  the  minimum  amount  needed  to 
secure  ease. 

The  bowels  must  be  kept  open.  In  some  cases  of  chronic 
intussusception  there  is  marked  constipation,  but  even  in 
the  cases  attended  with  diarrhcea  there  may  be  some  over- 
loading of  the  bowel  above  the  invagination. 

Relief  to  the  constipation  is  usually  to  be  afforded  by 
enemata.  Purgatives,  as  a  rule,  cannot  be  tolerated,  and 
are  to  be  avoided  owing  to  the  vigorous  peristaltic  action 
excited.  Reference  may  be  made  to  the  treatment  of 
constipation  in  the  instances  of  stricture  of  the  smaU 
intestine  or  of  the  colon  (pages  526  and  585). 

The  bowel  in  chronic  intussusception  is  narrowed  and,  so 
far  as  the  treatment  by  aperient  agents  is  concerned,  may  be 
regarded  as  strictured. 

As  soon,  however,  as  the  diagnosis  has  been  made  in  chronic 
intussusception,  operative  measures  should  be  employed. 
There  is  no  possible  excuse  for  delay.  The  cases  treated  by 
medical  measures  end  in  death,  although  the  dying  may  be 
long  protracted. 

The  use  of  forcible  enemata  in  intussusception  has  been 
fully  discussed  in  a  previous  chapter  (page  501). 

This  measure  is  hardly  applicable  to  the  present  type  of 
invagination,  although  cases  are  recorded  in  which  intussuscep- 
tions which  have  existed  for  some  weeks  have  been  success- 
fully reduced  by  enemata. 

As  the  efficacy  of  this  measure  in  really  chronic  intussus- 
ception is  very  doubtful,  and  as  its  power  to  do  harm  is  not  so 
uncertain,  it  had  better  be  dispensed  with  and  laparotomy 
performed  at  once. 

The  operative  treatment  of  intussusception  has  already 
been  considered,  and  what  has  been  said  of  acute  invagination 
applies  with  obvious  modifications  to  the  chronic  type. 

The  invagination  has  been  reduced  by  operation  after  the 
symptoms  have  existed  for  forty-four  days,*  for  seven  weeks,t 

*  Lancet,  vol.  i.,  1897,  p.  1137. 
t  Ibid.,  vol.  i.,  1889,  p.  171. 


552  TREATMENT    OF   FJ^CAL    ACCUMULATION. 

and  for  ten  weeks."^  Mr.  Page  reduced  an  invagination  which 
is  supposed  to  have  existed  lor  three  months.t  Reduction  by 
operation  at  the  end  of  six  months  is  reported  by  both  Czerny 
and  Rydygier.  The  latter  author  records  an  instance  of  such 
reduction  nine  months  after  the  onset  of  the  symptoms. 

It  need  not  be  said  that  in  the  majority  of  the  cases 
reduction  is  impossible.  In  such  examples  the  surgeon 
should  carry  out  Barker's  operation  of  partial  excision  or 
should  remove  the  entire  invaginated  portion  of  the  bowel, 
uniting  the  divided  ends  of  the  gut  after  such  removal. 

Should  these  measures  be  rendered  impossible  by  the  size 
of  the  intussusception,  or  by  the  presence  of  substantial 
adhesions,  the  question  of  short-circuiting  has  to  be  con- 
sidered. 

Small  intussusceptions  are  best  treated  by  total  excision, 
and  large  ones  by  Barker's  operation. 

The  instances  calling  for  a  short-circuiting  operation  as 
the  only  means  of  affording  relief  must  be  very  rare  indeed. 

D.  FjiCAL  Accumulation. — It  is  not  necessary  to  discuss 
in  a  surgical  work  the  treatment  of  chronic  constipation.  It 
will  only  be  desirable  to  indicate  in  the  barest  manner  the 
lines  upon  which  that  treatment  is  conducted. 

In  many  cases  of  chronic  constipation  the  trouble  depends 
upon  faulty  digestion  and  upon  the  entrance  into  the  colon  of 
masses  of  ill-digested  food. 

In  some  of  these  examples  the  patients  have  defective 
teeth  or  are  entirely  lacking  in  masticating  teeth,  or  the  teeth, 
if  perfect,  do  not  come  into  efficient  line. 

In  other  cases  the  food  is  bolted,  meals  are  taken  at 
irregular  times,  and  no  attempt  at  resting  after  meals  is 
observed ;  or,  on  the  other  hand,  the  food  taken  may  be 
indigestible,  and  many  cases  have  been  recorded  in  which  the 
bowel  has  been  blocked  by  masses  of  chewed  nuts,  gooseberry 
skins,  of  pineapple  fibre,  and  the  like.  The  food  taken  may 
be  of  a  digestible  character  in  the  abstract,  but  may  not 
be  capable  of  being  efficiently  digested  by  the  particular 
person.  For  example,  milk  is  an  admirable  article  of  food, 
but  some  adults  appear  to  be  incapable  of  digesting  it  if  given 
in  large  amount,  and  in  such  persons  the  undigested  milk 
will  form  hard,  scybalous  masses  which  have  more  than  once 
blocked  the  bowel 

That  form  of  dyspepsia  which  is  common  in  neurotic 
subjects  seems  to  be  peculiarly  favourable  for  the  production 
of  constipation. 

*  Obalinski. 

t  Trans.  Med.-Chir.  .Soc,  1878. 


APEBIEXTS.  553 

Quite  apart  from  imperfect  digestion,  constipation  may  be 
encouraged  by  the  avoidance  of  such  articles  of  food  as  excite 
peristaltic  action,  examples  of  which  are  afforded  by  certain 
fruits  and  vegetables. 

Certain  subjects  of  constipation  drink  so  little  fluid  that 
the  contents  of  the  bowel  cannot  be  maintained  in  a 
sufficiently  liquid  condition. 

In  other  cases  the  line  of  treatment  is  indicated  by  ob- 
servincr  that  the  patient's  muscular  condition  is  in  a  state  of 
feebleness,  that  a  proper  amount  of  exercise  is  not  taken,  that 
the  abdomen  is  flaccid  and  the  bowel  wall  in  a  state  of  atony, 
and  that  a  condition  is  present  which  may  be  remedied  by 
massage  and  suitable  exercises,  especiall}^  exercises  in  the 
open  air. 

In  the  treatment  of  chronic  constipation  massage,  com- 
bined with  exercises  and  electricity,  is  of  the  greatest  service. 

If  actual  blocking  of  the  bowel  be  produced  by  the  ac- 
cumulation of  faeces  in  the  colon,  the  following  course  of 
treatment  is  to  be  commended. 

If  the  patient  be  troubled  with  colicky  pains — as  is  most 
probable — such  distress  should  be  met  by  small  doses  of 
opium.  The  minimum  doses  necessary  to  relieve  pain  should 
be  given.  No  more  definite  treatment  can  be  undertaken 
until  these  disorderly  movements  of  the  bowel  have  been 
checked. 

Rest  in  the  recumbent  position  should  be  observed,  and 
in  most  cases  it  is  desirable  that  the  patient  should  be 
confined  to  bed. 

The  diet  should  be  restricted  to  the  very  simplest  elements 
and  should  consist  exclusively  of  fluid  food. 

If  vomiting  exists — and  it  will  seldom  be  other  than 
trifling — the  quantity  of  food  taken  by  the  mouth  should 
be  reduced  to  a  minimum. 

Aperients  can  seldom  be  tolerated.  They  will  probably 
have  been  given  literally  ad  nauseaiin  and  will  have  had  no 
eft'ect  upon  the  action  of  the  bowels.  Often  the  aperient  is 
vomited  and  if  retained  it  is  apt  merely  to  excite  colic  and 
ineffectual  straining.  Powerful  aperients  may  do  serious 
harm  and  in  a  case  of  simple  lyecai  impaction  I  have  seen  a 
heroic  purgative  reduce  the  patient  to  a  condition  of  collapse. 

It  is  desirable,  however,  that  as  much  fluid  as  possible 
should  be  poured  into  the  colon  from  the  small  intestine 
and  the  repeated  administration  of  small  doses  of  sulphate 
of  soda,  or  sulphate  of  magnesia  is  often  advantageous. 
These  drugs  should  not  be  given  in  sufficient  doses  to  cause 
colic. 

J  J  "^ 


554  TREATMENT    OF    F.EGAL    AG  CUMULATION'. 

In  cases  in  which  the  colon  is  simply  loaded  and  in  which 
there  is  neither  impaction  of  feces  nor  the  phenomena  ol 
intestinal  obstruction,  no  purgatives  are  of  greater  service 
than  castor- oil,  on  the  one  hand,  and  calomel,  given  in  small 
and  repeated  doses,  on  the  other. 

In  connection  with  this  subject  one  cannot  avoid  some 
mention  of  the  use  of  metallic  mercury. 

The  use  of  metallic  mercury  in  large  doses  is  of  very 
ancient  date  and  the  metal  was  at  one  time  regarded  as  a 
most  important  and  certain  remedy.  Many  cases  are  reported 
where  patients  suft'ering  from  severe  "  ileus  "  were  immediately 
relieved  by  a  large  dose  of  quicksilver.  It  is  needless  to  say 
that  this  mode  of  treatment  has  gone  more  or  less  out  of  use 
and  the  subject  would  hardly  have  merited  a  notice  were  it 
not  for  a  very  able  monograph  published  by  M.  Matignon, 
wherein  this  mode  of  treatment  is  once  more  advocated.* 
In  any  circumstances  M.  Matignon's  paper  cannot  fail  to 
be  read  with  considerable  interest,  and  it  is  from  this  pro- 
duction that  the  following  remarks  have  in  the  main  been 
gathered. 

The  cases  for  which  this  mode  of  treatment  are  best 
adopted  are  cases  of  obstruction  due  to  ftecal  accumulation. 

The  modus  operandi  is  as  follows : — The  mercury  does 
not  act  by  its  weight,  but  in  its  passage  along  the  intestine 
it  becomes  very  Hnely  divided,  and  on  reaching  the  faecal 
tumour  it  is  assumed  to  insinuate  itself  among  the  parts 
of  the  mass  and  between  the  mass  and  the  bowel  wall,  and 
so  to  loosen  the  obstructing  matter  as  to  restore  the  normal 
passage.  This  mechanical  action  is  aided,  no  doubt,  by 
some  peristaltic  action  that  the  foreign  substance  may 
excite  in  the  intestinal  wall  as  it  passes  along.  In  any 
case  the  metal  appears  to  have  been  passed  in  a  state  of 
extremely  fine  division  and  not  in  a  coherent  mass  as 
when  swallowed.  In  cases  of  acute  and  of  complete 
mechanical  obstruction  the  quicksilver  -has  been  found  after 
death  to  have  collected  into  a  single  mass  above  the 
obstruction,  the  separated  particles  having  in  such  instances 
cohered  again.  In  no  instancy  has  any  evidence  of  mer- 
curial poisoning  been  produced.  In  "several  of  the  cases 
where  this  treatment  was  adopted  the  vomiting  and  pain 
were  immediately  subdued  after  the  mercury  had  been 
swallowed,  and  this  result  is  supposed  to  be  due  to  the 
interference  with  the  movements  of  the  stomach  which 
the  metal  may  effect  by  its  mere  weight. 

*  Du  Traitement  de  I'Occlusion  intest.  par  le  Morcure  metallique  a  Haute 
Dose.     These  de  Paris,  No.  340,  1879. 


ENEMATA.  •■  555 

The  dose  of  the  inetal  administered  varies  Iroin  50  to 
300  grammes,  and  in  most  cases  the  dose,  Avhether  lai-ge 
or  small,  has  been  many  times  repeated. 

M.  Matignon  reports  several  cases  of  relief  by  this  treat- 
ment in  obstruction  due  to  fiecal  accumulation.  In  these 
examples  purges  and  enema ta  had  failed,  the  symptoms 
had  become  very  grave,  and  in  some  the  vomiting  had 
become  stercoraceous.  Metallic  mercury  was  administered, 
with  the  result,  that  the  vomiting  and  pain  were  immedi- 
ately relieved  and  the  bowels  were  caused  to  act  after  a 
few  hours.  In  each  of  the  cases  quicksilver  was  passed 
in  a  finely  divided  state  for  some  three  or  four  days  after 
the  first  evacuation,  and  in  one  instance,  where  nearly 
1,000  grammes  of  mercury  had  been  given  in  several  doses, 
the  metal  was  noticed  in  the  motions  for  seventeen  days 
after  the  administration  of  the  last  dose. 

M.  Matignon's  cases  appear  so  clear  that  in  any  case  of 
fgecal  accumulation  that  has  resisted  the  action  of  aperients, 
enemata,  massage,  etc.,  the  use  of  metallic  mercury  in  large 
doses  would  seem  to  be  worth  considering,  especially  as  the 
mode  of  treatment  appears  to  be  attended  by  no  especial 
risk. 

In  cases  of  fsecal  accumulation,  it  is  obvious  that  the  main 
feature  m  the  treatment  is  to  remove  the  faecal  mass,  and  this 
is  to  be  done  by  means  of  enemata. 

The  mode  of  procedure  varies  a  little,  according  to  the 
position  of  the  accumulation. 

When  the  rectum  is  blocked,  the  mass  may  be  removed 
by  enemata,  given  with  Higginson's  syringe.  The  material 
used  may  be  warm  soap  and  water,  or  the  salt  enema,  which 
consists  of  one  tablespoonful  of  salt  to  one  pint  of  warm  water. 

Failing  these,  the  enema  may  be  made  to  contain  one  or 
other  of  the  reputed  "  solvents  "  of  fsecal  matter.  The  most 
common  of  these  is  the  injection  composed  of  soap  and 
water,  to  which  a  little  turpentine  has  been  added.  Another 
injection  is  composed  of  olive  oil,  or  of  olive  oil  and  fresh  ox 
bile,  mixed. 

Some  medical  men  recoimnend  enemata  containing 
aperients,  such  as  castor-oil,  sulphate  of  magnesia,  aloes,  and 
the  like. 

Enemata  of  glycerine  are  not  suited  for  cases  in  which  the 
rectum  is  actually  blocked.  They  produce  much  straining 
and  unnecessary  distress. 

Failing  the  removal  of  the  mass  with  enemata,  the  patient 
nuist  be  an.-csthetised,  the  sphincter  dilated  l^y  the  fingers 
and  the  mass  removed  with  fcjrceps  and  scoops.     After  such 


556  TREATMENT    OF   F.ECAL    ACCUMULATION, 

removal  the  rectum  should  be  washed  out  by  irrigation,  while 
the  patient  is  still  under  the  ani3esthetic. 

When  the  fsecal  mass  is  lodged  in  the  sigmoid  flexure  or 
in  the  colon  above  it,  the  surgeon  has  to  trust  solely  to 
enemata. 

In  these  cases  any  form  of  syringe  or  pump  is  to  be  con- 
demned. Such  an  appliance  causes  the  fluid  to  be  introduced 
in  an  intermittent  and  spasmodic  manner,  of  which  the  bowel 
is  ver}^  intolerant. 

The  injection  should  be  given  by  means  of  a  douche 
apparatus,  by  the  use  of  which  a  continuous  and  easily 
regulated  pressiu'e  can  be  maintained. 

The  douche  can  should  be  of  glass,  and  should  be 
graduated.  It  is  convenient  if  it  be  large  enough  to  con- 
tain two  quarts.  To  the  can  is  attached  a  rubber  tube 
six  feet  long,  provided  with  a  tap  near  to  the  distal  end. 
To  the  tube  beyond  the  tap  is  attached  a  soft  rubber  anal 
tube  of  large  calibre,  six  inches  in  length  and  with  a  ter- 
minal opening. 

The  best  position  of  the  patient  is  lying  upon  the  left 
side  with  the  buttocks  much  raised  upon  a  sand  bag  or 
hard  pillow. 

Another  position  advised  by  some  is  the  knee  and  left 
shoulder  position.  This  position  is,  however,  uncomfortable 
and  irksome  and  cannot  be  long  maintained.  The  dorsal 
position,  with  the  buttocks  well  raised,  has  been  proved  to  be 
efficient  and  not  uncomfortable.  After  the  anal  tube  has 
been  introduced  into  the  rectum,  the  tap  is  turned  and  the 
douche  can  is  slowly  raised  above  the  level  of  the  patient's 
body.  The  height  to  which  the  can  is  ultimately  raised 
should  be  between  two  and  three  feet.  An  elevation  of  over 
three  feet  above  the  patient's  body  is  not  desirable.  An 
elevation  of  one  or  two  feet  will  be  sufficient  in  the  case 
of  a  child. 

The  fluid  used  for  the  injection  should  be  the  normal  salt 
solution  at  the  temperature  of  100°  F. 

In  the  administration  of  this  injection  certain  points  have 
to  be  observed.  The  enema  can  effect  the  surgeon's  purpose 
in  two  ways.  The  fluid  may  be  made  so  to  distend  the  colon 
as  to  provoke  peristaltic  movement  and  so  encourage  the 
natural  discharge  of  the  faecal  mass.  In  such  case  the  escape 
of  fluid  from  the  anus  must  be  as  far  as  possible  prevented, 
and  to  effect  this  end  it  is  well  that  the  anal  tube  should  be 
attached  to  a  handle  and  hilt  similar  to  that  belonging  to 
Lund's  insufflator  (Fig.  117).  On  the  other  hand,  the  fluid 
may  be  made  use  of  actually  to  wash   out    the  colon.      In 


ENEMATA.  557 

this  case  the  anal  aperture  must  be  left  free,  and  the  anal 
tube  should  be  double  and  arranged  on  the  principle  of  a 
double-current  catheter.  A  Turck's  double  colon- tube  meets 
this  end. 

In  the  washing  out  of  the  bowel  several  gallons  of 
water  may  be  employed  and  the  injection,  if  not  at  once 
efficacious,  may  need  to  be  repeated  every  day  until  the 
bowel  is  cleared.  There  is  no  doubt  but  that  the  douching 
or  irrigation  of  the  colon  is  more  eflficacious  than  the  "  forcible 
enema."  When  the  abdomen  is  much  distended  the  forcible 
enema  cannot  be  tolerated,  while,  on  the  other  hand,  irrigation 
of  the  colon  does  not  add  to  the  already  existing  distension. 

It  is  well  to  remember  that  the  dislodgment  of  long- 
retained  fsecal  masses  is  often  attended  with  considerable 
constitutional  disturbance.  It  would  seem  that  septic  absorp- 
tion from  the  bowel  is  the  cause  of  this  disturbance.  After 
the  breaking  up  of  the  fsecal  accumulation  it  is  common  for 
the  patient  to  experience  a  condition  of  inalaise,  with  head- 
ache and  possibly  nausea  and  a  marked  rise  of  temperature. 
In  one  or  two  of  these  cases  severe  urticaria  has  attended 
the  febrile  disturbance. 

When  once  the  removal  of  a  faecal  accumulation  is 
attempted  it  is  well  that  the  treatment  should  be  persevered 
with  until  the  colon  has  been  emptied. 

During  the  progress  of  such  treatment  gentle  massage  of 
the  abdomen  may  be  employed  and,  above  all,  hypodermic 
injections  of  strychnia  (^Vth  of  a  grain)  may  be  given  three 
times  a  day.  There  is  no  doubt  but  that  the  strychnia  is  of 
considerable  service. 

As  a  means  of  counteracting  the  septic  absorption  from 
the  bowel  the  administration  of  salol  in  ten-grain  doses  night 
and  morning  appears  to  have  good  effect. 

After  the  bowel  has  been  emptied,  means  should  be  taken 
to  prevent  a  recurrence  of  the  accumulation.  These  means 
will  take  the  form  of  careful  dieting,  of  attention  to  the 
digestion,  of  the  discreet  use  of  aperients  and  enemata,  and 
of  the  employment  of  massage  of  the  abdomen  and  electricity. 
Dail}'  massage  of  the  belly  is  one  of  the  most  admirable 
means  of  counteracting  the  severer  type  of  chronic  con- 
stipation. 

There  are  several  methods  of  applying  electricity  in  these 
cases  of  obstruction.  1.  Both  electrodes  are  placed  upon  the 
abdomen  ^  abdominal  method.  2.  One  pole  (the  negative) 
is  placed  upon  the  abdomen,  the  other  just  within  the  anus 
=  ano-abdorainal.  3.  One  electrode  (the  negative)  is  placed 
over    the   dorsal   spine   while    the    other  is  introduced  some 


558  TREATMENT    OF    FAECAL    ACCUMULATION. 

distance  up  the  rectum  =  recto-spinal.  4.  The  negative 
pole  touches  the  abdomen  while  the  positive  is  applied  within 
the  rectum  =  recto-abdominal.  In  the  two  last-mentioned 
methods  the  electrode  is  made  of  a  copper  ball  mounted  on 
an  isolating  handle,  so  that  the  current  may  pass  to  the  gut 
direct  without  involving  the  anus  and  lower  part  of  the 
rectum.  In  all  cases  and  in  all  forms  the  faradic  current 
is  advised.  The  method  most  particularly  advocated  by 
those  who  have  written  upon  the  subject  is  the  recto-abdo- 
minal. The  effects  that  have  been  claimed  for  this  lorm 
of  electric  application  are  the  following :  The  abdominal 
muscles  contract ;  the  intestines  contract  and  propel  forwards 
their  contents ;  flatus  disappears  from  the  intestine  without 
being  expelled  either  from  the  mouth  or  the  anus. 

The  various  mechanical  methods  adopted  for  the  relief 
of  constipation  in  what  is  usually  known  as  the  "  Swedish 
movement  cure  "  seem  to  have  met  with  a  very  encouraging 
degree  of  success.  The  machines  employed  are  of  different 
descriptions.  In  one  the  patient  lies  upon  the  abdomen 
over  an  opening,  and  in  this  opening  rollers  move  Avhich 
exercise  a  kneading  action  over  the  whole  of  the  belly.  In 
another  machine  two  rollers  are  caused  to  rotate  along 
the  course  of  the  large  intestine. 

In  other  forms  of  apparatus,  passive  rotation  of  the  lower 
part  of  the  trunk  and  passive  oscillation  of  the  pelvis  are 
brought  about,  with  the  effect,  it  is  said,  of  stimulating 
peristaltic  movements  in  the  intestine.  In  still  other 
machines,  the  patient  sits  upon  a  saddle,  and  is  subjected 
to  movements  which  imitate  more  or  less  the  movements 
incident  to  horse  exercise. 

An  account  of  apparatus  for  the  employment  of  me- 
chanical massage  has  been  given  by  Dr.  Herschell  in  a 
recent  communication.  "^ 

*  Clinical  Journal,  London,  November  23,  1898. 


559 


CHAPTER  YI 

THE    PROGNOSIS    AFTER    OPERATION    FOR    CHRONIC 
INTESTINAL    OBSTRUCTION. 

So  many  different  conditions  are  included  under  the  term 
chronic  intestinal  obstruction  that  it  is  difficult  to  give  in 
a  lew  words  a  correct  estimate  of  the  prognosis  of  the 
operations  taken  for  its  relief. 

Obstruction  due  to  faecal  impaction  should  yield  to  the 
measures  detailed  for  clearing  out  the  colon  and  should 
never  demand  a  cutting  operation. 

Patients  with  faecal  impaction  may  die  of  exhaustion, 
of  intestinal  septicsemia,  of  peritonitis,  of  colitis,  or  the 
like.  The  treatment,  if  undertaken  in  good  time  and  while 
the  bowel  is  still  in  good  condition,  may  be  expected  to 
be  attended  with  success  and  indeed,  in  uncomplicated  cases 
of  obstruction  due  to  faecal  accumulation,  the  clearing  of 
the  colon  is — if  sufficient  pains  be  taken — as  a  rule  effected 
with  certainty. 

I  am  not  aware  that  an  uncomplicated  case  of  fa?cal 
accumulation   has  called  for  an  abdominal  section. 

The  operations  for  chronic  intussusception  are  now 
attended  with  satisfactory  results  if  the  operation  be  not 
too  long  delayed.  The  matter  has  been  alluded  to  in  pre- 
vious sections  (page  521). 

Chronic  obstruction  due  to  the  bending  or  kinking  ot 
the  bowel  by  adhesions  demands  an  operation  of  little 
magnitude,  which  should  be  attended  with  success  in 
nearly  all  the  cases  in  which  the  operation  is  undertaken 
in  good  time. 

The  relief  of  obstruction  due  to  gall  stones  or  enteroliths  is 
effected  with  less  risk  when  the  obstruction  is  of  a  chronic 
typethan  when  the  symptoms  produced  are  acute. 

It  is  quite  impossible  to  formulate  the  risk  involved  in 


560  FROGNOSIS    IN    CHRONIC    OBSTRUCTION. 

operating  upon  cases  of  obstruction  due  to  the  pressure 
of  a  tumour  outside  the  bowel,  inasmuch  as  the  conditions 
involved  are  subject  to  so  great  variation. 

The  operation  of  excision  of  a  portion  of  bowel  for  malig- 
nant disease  is,  in  my  opinion,  one  of  the  greatest  value. 
The  treatment  of  cancer  by  free  excision  is  strikingly  success- 
ful when  the  malignant  growth  involves  the  bowel,  and  par- 
ticularly when  it  concerns  the  colon.  Patients  who  have 
been  subjected  to  such  excision  have  remained  free  from 
any  return  of  the  disease  for  peiiods  of  three  and  four  years 
and  even  for  longer  stretches  of  time. 

I  would  estimate  the  present  mortality  of  excision  of  the 
bowel  for  malignant  disease  at  about  20  per  cent,  and  the 
mortality  of  short-circuiting  operations  at  about  12  per  cent. 
It  is  to  be  remembered  that  the  majority  of  these  operations 
concern  the  colon. 

As  in  like  measures  for  other  forms  of  obstruction,  the 
great  element  in  success  depends  upon  the  performance  of 
the  operation  at  the  earliest  possible  period.  The  danger 
in  an  excision  of  the  bowel,  or  in  a  short-circuiting  operation, 
is  to  be  measured  mainly  by  the  degree  of  distension  of  the 
bowel  at  the  time  of  the  operation. 

When  abdominal  section  is  performed  as  early  as  possible, 
the  mortalit}^  of  the  operations  in  question  will  still  further 
decline. 

The  mortality  of  colotomy  performed  for  chronic  intestinal 
obstruction  may  be  placed  at  between  5  and  10  per  cent. 

Colotomy  has  been  largely  replaced  by  short-circuiting 
operations  and  the  cases  in  which  colotomy  is  now  performed 
are  often  complicated  and  have  been  not  infrequently 
neglected. 

There  is  little  reason  why  colotom}^,  when  performed  for 
chronic  obstruction,  should  not  be  attended  with  the  little 
risk  which  is  now  associated  with  that  operation,  when 
performed  for  rectal  carcinoma. 


INDEX. 


Alidominal  taxis  in  acute  obstruction,  466 

Accumulation  of  feces,  '275 

Acquired  diverticula,  57 

Acute  diseases  mistaken  for  olistniction,  439 

ending  in  chronic  obstruction,  435 

intussusception,  Sym7)toms  of,  348 

,  Treatment  of,  499 

obstruction,  285 

,  Diagnosis  of,  321 

,  Operation  in,  475 

,    Prognosis     after    operation,    fur, 

519 

,  Symptoms  of,  323 

,  Treatment  of,  449 

strangulation.  Operations  for.  494 

,  Prognosis  in,  373 

Adenoma  of  intestine,  259 
Adhesions,  Attachments  of.  84,  75,  80 

,  Causes  of,  25 

,  Formation  of,  27 

,  Obstruction  produced  by,  24,  75,  80 

,  Multiple,  31 

,  Strangulation  by,  25,  36,  75,  SO 

Age  in  intestinal  obstruction,  7 

Anomalous  forms  of  obstructions  by  Ijands, 

75 
Anti  peristalsis,  302 
Aperients  in  treatment  of  chronic  obstruction, 

527,  535 
Apertures,  Strangulation  through,  65,  68 
Ajipendices  epiploic*,  Strangulation  by,  64, 

68 
Appendix  vermifoimis.   Intussusception    of, 

181 

,  Strangulation  by,  62 

Arsenic  poisoning  mistaken  for  obstruction, 

446 
Auscultation  of  Colon,  319 
Avenoliths,  196 


Ballooning  of  rectum,  S'J'.I,  413 
Bands,  Attachments  of,  34,  75,  80 

• and  peritonitis,  25 

,  Causes  of,  25 

,  Disposition  of,  30,  75 

due  to  Meckel's  diverticulum,  40 

,  Formation  of,  27 

,  Multiple,  31 

,  Olistruction  produced  by,  24,  75,  SO 

,  Solitary,  25,  31,  46 

,  Strangulation  by,  24,  36,  75,  80 

,  ,  Prognosis  in,  373 

,  ,  Symptoms  of,  333 

Bending  of  the  bowel,  Obstruction  due  to,  80 
Bladder  communicating  with  colon,  62 


Blocking  of  bowel  by  fajces,  275 
Bowel,  Union  of  when  divided,  546 
Broad  ligament.   Strangulation   through   slit 
in,  69 


Ciffium,  Folds  about,  121 

,  Fossae  about,  121 

,  Hernia  about,  121 

,  Volvulus  of,  133 

Cancerous  stricture,  220 

Cancer  of  intestine,  220 

Catarrhal  ulcer,  214 

Catarrh  of  intestine,  18 

Cholera  mistaken  for  obstruction,  444 

Chronic  intussusception,  351 

,  Symptoms  of,  417 

,  Tieatment  of,  550 

obstruction,  286 

,  Diagnosis  of,  322 

,  ending  acutely,  435 

,  Prognosis  after  operation  for,  559 

,  Symptoms  of,  391 

,  Treatment  of,  523 

Clinical  torms  of  intestinal  obstruction,  2S6 

Coils  visible  of  intestine,  304,  315 

Colic  intussusception,  144 

Colitis,  201 

Collapse  in  intestinal  obstruction,  289 

Colon,  Bending  of,  98 

,  Chronic  obstruction  of.  Symptoms  of, 

408 

communicating  with  bladder,  62 

,  Congenital  diverticulum  of,  56 

,  Congenital  stricture  of,  238 

,  Deformities  of,  239 

,  Idiopathic  dilatation  of,  242 

,  Stenosis  of,  Operations  for,  540,  549 

,  ,  Symptoms  of,  408 

,  Stricture  of,  Ojierations  for,  540 

,  ,  Prognosis  in,  432 

,  ,  Syniptoms  of,  40S 

,  Volvulus  of,  133 

r.  small  intestine  in  obstruction,  310 

Colotomy,  545 

Compression  of  intestine,  269 

by  adhesions,  88 

Concretions,   Obstruction   bv,  Svmiitoms  of, 
372 

,  Obstruction  due  to,  197 

Congenital  diverticulum,  55 

malformation  of  bowel,  239 

stricture  of  intestine,  232 

Constipation,  275 

,  Causes  of,  275 

,  Extreme  cases  of,  424 

in  intestinal  obstruction,  304 

Course  of  acute  intestinal  obstruction,  373 


562 


INDEX. 


Course  of  ehronic  intestinal  obstruction,  430 
Cysts  of  intestine,  261 


Deformities  of  bowel,  239 
Dermoids  of  intestine,  262 
Diagnosis  of  intestinal  obstruction,  321,  439 

ot  site  of  obstruction,  310 

Diaphragmatic  hernia,  103 
Dilatation,  Idiopathic,  of  colon,  242 
Distended  coils  of  bowel,  304,  315 
Diverticular  cords,  45 

ligaments,  45 

Diverticulum,  Acquired,  57 

,  Congenital,  55 

of  colon,  56 

of  duodenum,  55 

of  rectum,  57 

of  small  gut,  56 

distension,  57 

Meckel's.     See  Mediel's  diverticulum. 

Duodeiuil  hernia,  107 

ulcer,  204 

Duodenum,  Congenital  diverticulum  of,  55 

,  Stricture  of,  232 

,  Stricture  of.  Symptoms  of,  406 

Dysenteric  stricture,  210 
Ulcer,  210 


E 

Eiiemata  in  diagnosis,  317 

in  ftecal  accumulation,  555 

in  treatment  of  intussusception,  501 

Enteric  intussusception,  143 

Enteroliths,  Obstruction  by.   Treatment  of, 
516,  531 

,  Obstruction  by.  Symptoms  of,  372 

,  Obstruction  due  to,  194 

Bnteroplasty,  527,  541 
Enterostomy,  481,  488,  529 
Epitlielioma  of  intestine,  220 

and  intussusception,  169 

Excision  of  bowel,  52S,  530,  642,  546 


F 

Fallopian  tube.  Strangulation  by,  63 
False  ligaments.     See  Bands. 
Feeding  in   treatment  of  acute  obstruction, 
459 

in  treatment  of  chronic  obstruction,  523, 

533 

Fibromata  of  intestine,  262 
Fil)ro-niyomata  of  intestine,  262 
Fistula  bimucosa,  93 
Ficcal  accunuilation,  275 

,  Prognosis  in,  433 

,  Symptoms  of,  421 

,  Treatment  of,  550 

tumour,  425 

Freces,  Accumulation  of,  275 

,  Sliape  (if,  in  chronic  obstruction,  394 

Follicular  ulcer,  214 

Foraiucn  of  Winslow,  Hernia  into,  115 

Foreign  bodies  above  an  obstruction,  21 

,  Obstruction  by.  Symptoms  of,  371 

,  Treatment  of,  516,  531 

,  Obstruction  due  to,  185 

Fossa  duodeno-jejunalis,  107 

,  Ileo-csecal,  122 

,  Ileo-colic,  122 


Fossa,  Intersigmoid,  119 

,  Sub-cKcal,  122 

Frequency  of  intestinal  obstruction,  7 


G 

Gall  stones  and  voUoilus,  136 

,  Obstruction  by.  Prognosis  in,  i 

,  ,  Symptoms  of,  363 

,  ,  Treatment  of,  516,  531 

,  Obstruction  due  to,  191,  367 

Gangrene  of  intestine,  12,  19 

of  bowel  met  with  in  uperating,  491 

,  Treatment  of,  491 


Hernia  about  csecum  ,121 

,  Diaphragmatic,  lu3 

,  Duodenal,  107 

,  Ileo-csecal,  123 

,  Internal,  102 

,  Intersigmoid,  119 

into  foranien  of  Winslow,  115 

into  fossa  duodeno-jejunalis,  107 

,  Mesenteric,  107 

,  Mesocolic,  107 

,  Mesogastric,  107 

of  Treitz,  107 

,  PeriCcecal,  121 

,  Retroperitoneal,  107 

,  Stricture  due  to,  218 

,  Sub-caecal,  122 

Hypertrophy  of  intestine,  17 
Hysteria  ndstaken  for  obstruction,  446 


Idiopathic  dilatation  of  colon,  242 
lleo-cfecal  fossa,  122 

hernia,  123 

-intussusception,  144 

■  -salve,  Stricture  of,  Symptoms  ot 

407 

,  Stricture  of,  218 

Ileo-colic  fossa,  122 

intussusception,  145 

Ileus  paralyticus,  280 
Indicanuria,  308,  320 
Injury,  Stricture  due  to,  218 
Internal  hernia,  102 

strangulation.  Symptoms  of,  333 

Intersigmoid  hernia,  119 
Intestinal  obstruction.  Age  in,  7 

,  Classification  of,  3 

,  Clinical  forms  of,  6,  285 

,  Course  of,  373,  430 

,  Diagnosis  of,  310,  321,  439 

,  Frequency  of,  7 

,  General  pathology  of,  9 

,  General  view  of,  1 

,  Mechanical  forms  of,  4 

,  Meclianisni  of,  70,  72 

,  Morbid  anatomv  of,  24 

,  Mortality  of,  373,  430,  519,  559 

,  Nature  of,  1 

,  Operation  in,  475,  494,  540 

,  Prognosis  in,  373,  430,  519,  559 

,  Sex  in,  7 

,  Symptoms  of,  285,  289 

,  Treatment  of,  449,  523 

Intestine,  Adhesions  of,  80 

above  an  obstruction,  10,  17 

below  an  obstruction,  11,  16 


INDEX. 


563 


Intestine,  Bending  of,  80 

,  Cancer  of,  220 

,  Catarrli  of,  IS 

,  Cniiiiiression  of,  S8 

,  Epitlielioiua  ot,  220 

,  Gangrene  of,  12,  19 

,  Hypertrophy  of,  17 

,  Innocent  tninonrs  of,  259 

,  Looping  of,  91 

,  LynipliadenoMia  of,  205 

,  Matting  of,  90,  94 

,  Obstrnction  of,  16 

,  Occlnsion  of,  9 

,  Perforation  of,  19 

,  Polypi  of,  269,  2ti3 

■ ,  Sacculation  of,  20 

,  Saiconia  of,  207 

,  Strangulation  of,  9 

. ,  Stricture  of,  202 

•^—,  Tumours  of,  259 

,  Ulceration  of,  13 

,  Ulcers  of,  204 

,  Volvulus  of,  126 

,  Washing  out  of,  555 

Intussuscipiens,  142,  162 

,  Changes  in,  162 

Intussusception,  141 

,  Acute,  symptoms  of,  348 

and  epitlielioma,  ItiO 

and  Meckel's  diverticulum,  52,  180 

and  polypus,  179 

Bloodless  methods  of  treatment,  500 

Causes  of,  171 

Changes  in,  153,  li31 

Chronic,  Prognosis  in,  433 

,  Symptoms  of,  417 

Colic,  144 

Distension  of  bowel  in  treatment  of,  501 

Double,  151 

Elimination  by  gangrene  in,  384 

Elimination  of,  165 

Enteric,  143 

Experimental,  172 

Forcible  enemata  in  treatment  of,  501 

Forms  of,  351 

Frequency  of,  145 

Gangi'ene  of,  1(>5 

— ,  Treatment  of,  516 

Growth  of,  145 

Ileo-cieeal,  144 

Ileo-colic,  145 

Inflation  with  air  in,  509 

Irredueiliility  of,  158 

,  Treatment  of,  514,  550 

Multiple,  151 

Mysentery  in,  153 

Obstruction  of,  156 

of  the  dying,  148 

of  vermiform  appendix,  181 

,  Operative  treatment  of,  499,  512,  550 

,  Physiology  of,  171 

,  Prognosis  in,  879,  433 

• .  Retrograde,  151 

,  Slougliing  of,  165 

,  Spontaneous  cure  in,  381 

,  Strangulation  of,  156 

■ ,  Terms  applied  to,  142 

,  Tumour  in,  358,  361 

,  Use  of  hydrogen  in,  512 

,  Varieties  of,  143 

Intussusceptum,  143,  163 

,  Changes  in,  163 

Invagination.    i:ee  Intussusception. 


Kader's  experiments,  13 


Kinking,  Obstruction  due  to,  51,  77 

,  Strangulation  by,  51,  77 

Knot,  Strangulation  by  a,  37,  49 


Lead  colic  mistal<en  for  obstruction,  446 
Liponiata  of  intestine,  263 
L(jngtubein  diagnosis,  318 
Looping  of  intestine,  91 
Lymidiadenoma  of  intestine,  265 


M 

Malformation,  Congenital.  239 
Matting  of  intestine,  90,  94 
Massage  in  obstruction,  466,  500,  558 
Meckel's  diverticulum.  Attachments  of,  43 

and  intussusception,  52,  ISO 

,  Disposition  of,  42 

,  Intussusception  of,  ISO 

,  Strangulation  Ijy,  42,  47 

,  Stricture  of,  43 

,  Stricture  associated  with,  52 

,  Varieties  of,  42 

,  Volvulus  of,  52 

process,  Strangulation  by.  Symptoms  of 

333 
Meningitis  mistaken  for  ob^traction,  446 
Mercury  in  the  treatment  of  obstruction,  554 
Mesenteric  hernia,  107 

vessels.  Thrombosis  of,  447 

Mesentery,  Fixed,  Strangulation  by,  63 

,  Holes  in,  67 

•,  Shrinking  of,  100 

,  Slits  and  apertures  in,  65 

,  Strangulation  by  holes  in,  65 

Mesocolic  hernia,  107 

Mesogastrio  hernia,  107 

Meteorism,  307,  313 

— -  in  strangulation  of  the  Ijowel,  73 

,  Pathology  of,  13 

Morphia  in  treatment  of  acute  obstruction 

450 

• chronic  obstruction,  525,  534 

Mortality  after  operation  for  acute  ol)struo 

tion,  519 
chronic  obstruction,  559 

of  intestinal  obstruction,  373,  430 


N 

Noose,  Strangulation  by  a,  37,  48 


Oat  stones,  196 

Obstruction  by  acute  kinking,  77 

by  bending  of  the  Vmwel,  80 

by  gall  stones,  etc.,  191,  367 

due  to  external  pressure,  269 

•  due  to  tumours,  259 

of  bowel,  Acute,  6 

,  Degree  of,  5 

,  Chronic,  6 

,  Effects  of,  16 

,  Mechanical  forms  of,  4 

,  Pathology  of,  16 

,  Searcli  for,  in  operating,  484 

Occlusion  by  acute  kinking,  77 
of  bowel,  5 


564 


INDEX. 


Occlusion  of  bowel,  Effects  of,  9 

. ,  Pathology  of,  9 

Ome^'a  loop,  128 

Omental  cords,  Strangulation  liy,  39 

--,  ,  Symptoms  of,  333 

Omentum,  Slits  and  apertures  in,  (jS 

,  Strangulation  by  slits  in.  (58 

Opeiation  during  peritonitis,  492 

for  chronic  obsti-uction,  527,  540,  549 

in  acute  obstruction,  475 

,  Prognosis  of,  519 

in  chronic  obstruction.  Prognosis  of,  559 

in  extreme  cases,  4S1 

— —  for  intussusception,  512,  550 

for  uniting  bowel,  546 

Ovarian  pedicle,  Strangulation  by,  65 


Pain  in  intestinal  obstruction,  293 

Papilloma  of  intestine,  259 

Paralysis  of  bowel,  280 

Pathology  of  intestinal  obstruction,  9 

of  obstruction  of  bowel,  16 

of  occlusion  of  bowel,  9 

Perforation  of  intestine,  19 

PerictEcal  hernia,  121 

Peristalsis,  Visible,  304,  315 

Peritonitis  at  time  of  operation,  492 

mistaken  for  obstruction,  441 

Polypi  of  intestine,  259,  263 

Polypus  and  intussusception,  179 

Pouches  in  obstruction,  20 

in  the  colon,  61 

Prognosis  nfter  operation  f<jr  acute  obstruc- 
tion, 519,  559 

in  acute  intestinal  obstruction,  373  • 

in  chronic  intestinal  olistruction,  430 

intussusception,  433 

in  fsecal  accumulation,  433 

■ in  intussusception,  379,  433 

in  obstrnction  by  gall  stones,  388 

in  stenosis  of  colon,  432 

■ small  intestine,  430 

■ in  stricture  of  small  intestine,  430 

colon,  432 

— —  in  volvulus,  377 

Puncture  of  the  bowel  in  obstruction,  471, 
638 


R 


Rectal  feeding,  463,  524 

Rectum,  Ballooning  of,  399,  413 

Rest  in  treatment  of  acute  obstruction,  449 

Retroperitoneal  hernia,  107 


Sacculation  of  intestine,  20 
Sarcoma  of  intestine,  267 
Sex  in  intestinal  obstruction,  7 
Shoit-circuiting  the  intestine,  529,  54? 
Shrinking  of  mesentery,  100 
Sigmoid  flexure,  Symptoms   of   volvulus  of, 
339 

,  Volvulus  of,  126 

Signe  de  Dance,  358 

Site- of  obstruction,  310 

Slits,  Strangulation  througli,  65,  68 

Small  intestine,  Clironic  obstruction  of,  400 

,  Congenital  divei'tieulum  (if,  56 

-— ,  Stenosis  of.  Symptoms  of,  39D 


Small  Intestine,   Stricture  of.  Prognosis   in, 
430 

V.  colon  in  obstruction,  310 

,  Volvulus  of,  132,  135 

Snaring  of  tlie  bowel,  37,  48 
Solitary  bands,  25,  31,  46 
Stenosis  of  liowel,  Effects  of,  16 

,  Operative  treatment  of,  527,  540 

of  colon.  Prognosis  in,  432 

,  Symptoms  of,  408 

of  sujali  intestine.  Prognosis  in,  430 

,  Symptoms  of,  399 

Stercoraceous  vomiting,  300 

Stomach,   Washing   out    of,    in  obstruction, 

409 
Strangulation,  Amount  of  gut  involved  in,  71 
by  adherent   appendices   epiploiese,   61, 

6S 
vermiform  appendix,  62 

by  adhesions,  25,  36,  75,  80 

h)  a  noose,  37,  48 

byattache<l  structures,  62 

by  bands.  Anatomy  of,  24,  75 

,  Bowel  involved  in,  7 

,  Operative  treatment  of,  494 

. ,  Prognosis  in,  373 

,  Symptoms  of,  333 

,  Varieties  of,  24,  36,  75 

by  Fallopian  tube,  63 

by  false  ligaments,  25,  30,  75,  80 

by  fixed  mesentery,  63 

by  kinking,  51,  77 

,  Operative  treatment  of,  496 

by  knots,  37,  49 

by  Meckel's  diverticulum,  42 

process.  Operative  treatment  uf,  495 

by  omental  cords,  39 

by  ovarian  pedicle,  65 

of  bowel,  9 

,  Etiects  of,  10 

,  Path(jlogy  of,  9 

,  Mechanism  of,  70,  72 

,  Modes  of,  36 

over  a  band,  51,  75 

,  Part  of  gut  involved  in,  70 

through  mesenteric  holes,  65 

omental  holes,  68 

slits  and  apertures,  65 

under  a  baud,  36 

Stricture  after  hernia,  218 

injury,  218 

ulceration,  202 

■ associated  with   Meckel's  diverticidum, 

52 

,  Cancerous,  220 

,  Cicatricial,  202 

,  Congenital,  of  colon,  238 

, ,  of  duodenum,  232 

,  - — ,  of  small  intestine,  235 

,  Simple,  202 

of  bo\-.'el,  Changes  after,  16 

,  Effects  of,  16 

,  Operative  treatment  of,  527 

of  colon.  Prognosis  in,  432 

,  Symptoms  of,  408 

of  duodenum,  Symptoms  of,  406 

of  ileo-cfecal  valve,  218 

,  Symptoms  of,  407 

of  intestine,  202 

,  Clinical  aspect  of,  229 

,  Site  of,  231 

,  Varieties  of,  231 

of  small  intestine,  Prognosis  in,  430 

,  Symptoms  of,  399 

Sub-csecal  fossa,  122 

hernia,  122 

Symptoms  of  intestinal  obstruction,  286 
Syphilitic  stricture,  208 
I    ulcer,  208 


INDEX. 


56S 


Tliirst  in  acute  obstruction,  465 

Thrombosis  of  nieseiiteric  arteries,  447 

veins,  447 

Traction,  Obstruction  due  to,  77 

Treatment  by  operation  of  acute  stnuigiila- 
tion,  494 

,  General,  of  obstrurtion.  440,  ri23 

ofi-lironic  obstiiietion,  :r2.i 

of  intestinal  obstnatinu,  440,  528 

of  intussusception,  400,  550 

of  obstruction  by  gall  stones,  510,  531 

— —  of  stricture  of  bowel  by  operation,  527,  540 

Treitx's  hernia,  107 

Trophic  ulcer,  214 

Tuberculous  peritonitis  mistaken  for  obstruc- 
tion, 443 

stricture,  205 

ulcer,  205 

Tumour  forjued  of  farces,  425 

Tumours,  Obstruction  due  to  pressure  of,  269 

of  the  intestine,  250 

Twist  of  the  bowel,  12ii 

Tymp.'inites,  Pathology  of,  13 

Typhoitl  ulcer,  200 


u 


Ulcer,  Catarrhal,  214 

,  Duodenal,  204 

,  Dysenteric,  210 


Ulcer,  FoUii'ular,  214 

,  Syphilitic,  208 

,  Tuberculous,  205 

,  Typhoid,  200 

Ulceration  of  intestine,  18,  204 
Urine,  Diminution  of,  308 


Vascular  ulcer,  214 

Vermiform  appendix,  Strangulation  by,  62 
Visible  coils  of  bowel,  304,  315 
Volvulus  and  gall  stones,  136 

in  strangulation  of  the  bowel,  73 

of  caecum,  133 

,  Symptoms  of,  344 

of  colon,  133 

,  Svmptoms  of,  344 

of  Meckel's  diverticulum,  52 

of  sigmoid  flexure,  126 

,  Prognosis*  in,  377 

,  Symptoms  of,  339 

of  small  intestine,  132,  135 

,  Sym)5toms  of,  345 

,  Operative  treatment  of,  406 

Vomiting  in  intestinal  obstruction,  297 
.  Stercoraceous,  300 


w 

Washing  out  of  stomach  in  obstruction,  469 
Worms,  Obstruction  due  to,  200 


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COLUMBIA  UNIVERSITY   LIBRARIES 

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DATE  BORROWED 

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DATE  BORROWED 

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C28  (449)  M50 

RC862 


T72 
1904 


Treves 
Intestinal  obstructions. 


RGg^2^ 


T72 
1 10^ 


